266 intake-focused payer guides — state Medicaid programs, every Medicaid MCO, and commercial plans state by state — plus 852 searchable policy rules, each linked to its primary source. Compiled from primary documents, last reviewed September 2026.
Ask anything about the payers in our directory — prior auth, diagnosis requirements, rates, reauthorization. Answers come only from our verified guides, with sources cited.
AI-generated from Carelu's payer guides — verify against the payer's live policy for any specific member. Not billing, legal, or clinical advice.
Every state lists its Medicaid program, each Medicaid MCO, and the commercial plans operating there — each with its own intake-focused guide.
MCD-MM-0212 aligned to the DCH manual; in-house PA; 2026 rate change.
Assessment PA requiredGA.CP.BH.504; hour parameters + 80%-attendance rule; 0373T rules.
Assessment PA requiredCG-BEH-02 adaptive behavioral treatment; verify current version.
Assessment PA requiredCG-BEH-02 criteria + Ava’s Law mandate; caps, parity, billing rules.
CPB 0554 (ABA) + CPB 0648 (ASD) + the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate layer.
Assessment PA requiredStraight CCP 8F via Availity/ICR; RB-BHT exempt from network distance rules; CFSP sibling plan.
Assessment PA requiredCCP 8F deference; NaviNet + PA Lookup Tool; thinnest public paper trail of the NC plans.
Explicit CCP 8F deference + an ABA treatment-request checklist; statewide since 4/1/2026 (absorbed WellCare NC).
Assessment PA requiredThe Optum carve-out: separate assessment & treatment auths on Provider Express, own criteria.
Assessment PA requiredMERGED into Carolina Complete Health effective 4/1/2026 — no longer a standalone Standard Plan.
Tailored Plan publishing real rates + the strictest diagnostic-tool and service-order enforcement.
Assessment PA requiredTailored Plan with the best single reference doc: tiered 180/90-day TARs, adult coverage, GT/KX modifier rules.
Assessment PA requiredWestern-NC Tailored Plan; 8F via SARs to Vaya UM — key documents must be pulled manually.
Assessment PA requiredTailored Plan with the ALL-codes authorization: one auth covers every RB-BHT code via ProAuth.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the N.C.G.S. § 58-3-192 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the N.C.G.S. § 58-3-192 mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the N.C.G.S. § 58-3-192 mandate layer.
Assessment PA requiredIHCP criteria restated in Anthem's UM guideline; Availity/ICR submission, F84.0 + daily schedule.
Assessment PA requiredIHCP criteria + MHS's own OTR form: named diagnostic instrument, outcome measure, utilization reporting.
Assessment PA requiredDefers to IHCP criteria (own policy archived); portal-first PA, one-agency rule, ABA audit posture.
Assessment PA requiredENDED as an HIP/Hoosier Healthwise MCE effective 1/1/2026 — members reassigned to Anthem, CareSource, or MHS.
Assessment PA requiredHoosier Care Connect + PathWays for Aging ABA via the Optum carve-out — not HIP/Hoosier Healthwise.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the Ind. Code 27-8-14.2 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the Ind. Code 27-8-14.2 mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the Ind. Code 27-8-14.2 mandate layer.
Assessment PA requiredNo dollar, age, visit or hour cap in the mandate; Indiana now licenses LBAs; Anthem reviews in-house.
DMAS forms/criteria via Availity; the auth lives on the LBA's NPI — changes need a new auth.
No PA on assessmentDMAS forms via Availity/ICR; publishes the clearest code/modifier/POS grid in Virginia.
No PA on assessmentVirginia's newest MCO (7/2025, ex-Molina members); DMAS forms, one PA-list quirk on 0362T.
No PA on assessmentFirst to post the new DMAS units-per-code form; dedicated BCBA-change workflow, PAL lookup tool.
No PA on assessmentDMAS criteria with ABA carved to Optum: Provider Express submission, separate credentialing.
No PA on assessmentCPB 0554 (ABA) + CPB 0648 (ASD) + the Va. Code § 38.2-3418.17 mandate layer.
EN0499 + autism resource guide + the Va. Code § 38.2-3418.17 mandate layer.
Optum Supplemental Clinical Criteria (BH803ABASCC) + the Va. Code § 38.2-3418.17 mandate layer.
Assessment PA requiredEvery ABA code is on the precert list; criteria differ HMO vs PPO; $35K ABA cap still in statute.
Shared TennCare program via Availity/BCBST; 26-week auths, 7-day UM decisions.
Assessment PA requiredShared TennCare baseline + UHC's own Level of Care rules: physician order, 20-hr gate.
Assessment PA requiredShared TennCare program via Availity ICR; MD-order emphasis, <90% utilization rule.
Assessment PA requiredStatewide PIHP (VSHP) — separate contract from BlueCare; SSI kids, foster youth, IDD/CHOICES. 37,095 members.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the Tenn. Code Ann. § 56-7-2367 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the Tenn. Code Ann. § 56-7-2367 mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the Tenn. Code Ann. § 56-7-2367 mandate layer.
Assessment PA requiredThe strictest OH policy: named diagnostician specialties, ADOS/ADI-R/CARS-2, docs-before-claims.
Assessment PA requiredIn-network assessments PA-free; CP.BH.104 hour parameters (6/day, 30/wk) and school rules.
No PA on assessmentTracks state ABA policy; Availity-only PA since 1/2026 — key documents best pulled via portal.
CG-BEH-02 adopted on top of the state rule; Availity/ICR, EPSDT framing in the provider manual.
Optum's OH supplemental criteria: 80% utilization trigger, tool lists, Provider Type 19 detail.
State-rule-driven UM; NaviNet/Jiva workflow — thinnest public ABA paper trail of the OH plans.
Cleanest all-codes PA statement in Ohio; state-policy criteria plus Availity logistics.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the Ohio R.C. § 3923.84 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the Ohio R.C. § 3923.84 mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the Ohio R.C. § 3923.84 mandate layer.
Assessment PA required20 hrs/week is a floor, not a cap; individual and small-group plans are carved out; COBA required.
Largest NJ MCO; NaviNet requests, 32-unit assessment fast-track, MCG review, 6-month auths.
Assessment PA requiredClosest to the state baseline: published rate sheet mirrors the FFS schedule, MUE limits verbatim.
Assessment PA requiredEx-WellCare Centene plan; state-baseline ABA with no published plan policy — verify specifics.
Assessment PA requiredOptum-run; no comprehensive eval needed, school setting OK outside school hours, Provider Express intake.
Assessment PA requiredEx-Amerigroup Elevance plan; state-baseline ABA via Availity, with Carelon running the BH network.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the P.L. 2009, c.115 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the P.L. 2009, c.115 mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the P.L. 2009, c.115 mandate layer.
Assessment PA requiredA TRICARE Prime designated-provider plan that administers the ACD itself — Hopkins authorizes, not Humana Military.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + Maryland's habilitative-services mandate with 25/10-hr floors.
Assessment PA requiredEN0499 + autism resource guide + Maryland's habilitative-services mandate with 25/10-hr floors.
No PA on assessmentOptum BH803ABASCC + a published Maryland State Mandates entry adopting the COMAR 25/10-hr floors.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the C.R.S. § 10-16-104(1.4) mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the C.R.S. § 10-16-104(1.4) mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the C.R.S. § 10-16-104(1.4) mandate layer.
Assessment PA requiredAnthem reviews ABA in-house (not Carelon); weekly approved units since 3/1/2026; no mandate caps.
CPB 0554 (ABA) + CPB 0648 (ASD) + the Utah Code § 31A-22-642 mandate layer.
EN0499 + autism resource guide + the Utah Code § 31A-22-642 mandate layer.
Optum Supplemental Clinical Criteria (BH803ABASCC) + the Utah Code § 31A-22-642 mandate layer.
Assessment PA requiredNo PA on 97151/97152; 6-month auths on its own ABA form; serves ACC + DDD + DCS books.
No PA on assessmentOptum-run; PA on everything except 97151/97152; explicit "no ASD dx required" rule.
No PA on assessmentCentene's CP.BH.104 overlay: dx confirmation, 5-year eval recency, hour bands; every county.
State baseline + its own ABA PA form; specifics unpublished — verify in the Banner portal.
Now officially "Blue Cross Blue Shield of Arizona Health Choice"; grid-driven PA, no published ABA policy.
Smallest ACC footprint (3 Phoenix-metro counties); no published ABA policy — verify by phone.
The second funnel: ALTCS-DD members get ABA via Mercy Care DD or UHCCP DD, statewide.
CPB 0554 (ABA) + CPB 0648 (ASD) + Steven's Law with its caps repealed by SB 1590 (2025).
Assessment PA requiredEN0499 (no AZ carve-out) + Steven's Law with its caps repealed by SB 1590 (2025).
No PA on assessmentBH803ABASCC + Optum's AZ state-mandate entry reflecting SB 1590's cap repeal.
Assessment PA requiredLargest NY plan; full Centene-style policy: named instruments, graphs, 6-month reauth cycle.
State-baseline clinical criteria, but ALL ABA services are PA-gated through Optum's Provider Express.
Assessment PA requiredTreatment Plan Request Form via Availity; Comprehensive-vs-Focused framing; incomplete forms returned.
Own ABA authorization policy; PA routed through Availity Essentials — policy text unpublished, verify.
NYC H+H plan; auth via email/fax to CSS; unique quirk: diagnosis must be re-validated annually.
Published ABA content restates the state criteria verbatim; PA specifics unpublished — verify.
Ex-Affinity; ABA UM in-house since 9/2021 (formerly eviCore) — the classic stale-info trap.
Central/Western NY + Southern Tier; own named ABA medical policy (3.01.11) — but outpatient PA specifics sit behind the portal login.
In-house BH/ABA UM; PA required for both assessment and treatment — but 0362T/0373T are excluded from Medicaid Managed Care reimbursement.
Assessment PA requiredCapital District plan; ABA codes named in-house at CDPHP's own Behavioral Health Access Center — but PA specifics and limits sit behind the secure portal.
Erie County/Buffalo only (not Monroe); Carelon runs general BH, but ABA looks to be administered directly by Independent Health — confirm which before routing a case.
8 WNY counties; ABA requires authorization and carries a stated $45,000/year cap — delegate is Wellpoint Partnership Plan (a Carelon mention in the same manual is unresolved).
Assessment PA requiredTRICARE Prime designated provider across northern New England, upstate NY, northern PA and Ohio — administers the ACD directly.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the NY autism mandate: no ABA-only visit caps, no age limit, LBA-only.
Assessment PA requiredEN0499 + autism resource guide + the NY mandate: no ABA-only visit caps, no age limit, LBA-only.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the NY mandate: no ABA-only visit caps, no age limit, LBA-only.
Assessment PA requiredThe 680-hour cap was repealed in 2020; Empire is now Anthem; 28-county service area.
Shared state LOC criteria; ABA Clinical Service Request Form at least 2 weeks pre-start.
State criteria with its own Stage 3 review forms; Medicaid BH fax (505) 843-3019 — not Magellan.
New to NM 7/2024; PA via Availity Essentials; no published ABA policy — verify in portal.
Optum-run ABA; PA only on 97153 & 0373T; Provider Express; 6-month claim deadline.
No PA on assessmentCPB 0554 (ABA) + CPB 0648 (ASD) + the NMSA § 59A-22-49 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the NMSA § 59A-22-49 mandate layer.
No PA on assessmentOptum criteria (BH803ABASCC) + the NMSA § 59A-22-49 mandate + a Turquoise Care plan.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the RSMo § 376.1224 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the RSMo § 376.1224 mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the RSMo § 376.1224 mandate layer.
Assessment PA requiredInflation-indexed ABA cap ($57,311 for 2025); Anthem reviews in-house; 6-month statutory review ceiling.
TMPPM criteria; PA on every ABA code; the only STAR Health (foster care) plan statewide.
Assessment PA requiredOwn 30-page guideline (#11281 v3) that restates TMPPM; PA via portal, fax, phone, or mail.
Assessment PA requiredTMPPM restated; accepts its own ASD form OR the state CCP PA form; Availity submission.
Assessment PA requiredTMPPM criteria with ABA carved out to Optum's BH network — not the medical PA pipeline.
Assessment PA requiredTMPPM state baseline in Bexar & Tarrant; plan-specific PA mechanics not publicly verifiable.
TMPPM baseline; verify codes in Molina's PA Code Matrix — its PA guide PDFs sit behind bot walls.
Bexar-area plan with the clearest published TX ABA billing crosswalk — a TMPPM digest.
Assessment PA requiredSouth Texas plan using the statewide TARF form; per-code PA checks via its lookup portal.
Assessment PA requiredOwn ABA Medical Review Guideline (adopted 6/2026); TSPA+CCP form; 85% attendance rule on extensions.
Assessment PA requiredSTAR/STAR Kids in Travis; insourced BH from Magellan in 2024; PA code grid confirms 97151-97158.
Assessment PA requiredDedicated 123-page ABA training deck; 6-county Fort Worth-area STAR + STAR Kids; EpicCare Link portal.
Assessment PA requiredDallas County safety-net STAR plan; BH insourced from Carelon 9/1/2025; PA covers 97151-99366, not 0362T.
Assessment PA requiredEl Paso's founding Medicaid MCO (ex-El Paso First); 85% attendance rule; not the SDA's only plan.
Assessment PA requiredLubbock + MRSA West STAR/CHIP; PA confirmed on 97151-99366; plans wind down 8/31/2026 (pending approval).
Assessment PA requiredRightCare/MRSA Central — plan is WINDING DOWN, exits Texas Medicaid 8/31/2026 (regulatory approval pending).
Assessment PA requiredEstablished pediatric plan (STAR since 2012), Travis SDA (8 counties); ABA delegated to Magellan BH.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the Tex. Ins. Code § 1355.015 mandate layer.
EN0499 (no TX carve-out) + the Tex. Ins. Code § 1355.015 mandate layer; no TX Medicaid plan.
Optum criteria (no TX mandate entry) + the Tex. Ins. Code § 1355.015 mandate layer.
Assessment PA requiredThe biggest MA ABA gatekeeper: PCC Plan + Primary Care ACOs + HNE, Carelon-run, standard form.
Assessment PA requiredLargest ACPP footprint (8 of 15) + Essential MCO; insourced BH from Carelon 1/1/2026, hosts the standard form.
Assessment PA requiredMCO product discontinued 1/1/2026 — only its 2 ACPPs (w/ Cambridge Health Alliance, w/ UMass Memorial) remain.
Three ACPPs (2023 roster), Carelon-run BH, state-baseline rules; first-wave audit recoupments.
Assessment PA requiredWestern-MA ACPP (BeHealthy Partnership); ABA auth is the MBHP flow, state-baseline rules.
Assessment PA requiredThe Optum-run MassHealth ACPP: BH803ABA state supplement, 30 hr/wk EI cap, codified 1:10 ratio.
Assessment PA requiredCPB 0554/0648 + ARICA (no caps, any age) + Aetna's own hosted MA Standard ABA form.
Assessment PA requiredEN0499 (no MA carve-out) + ARICA's no-cap, any-age floor for fully-insured plans.
No PA on assessmentOptum BH803ABASCC + ARICA + two explicit MA entries in Optum's state-mandate supplement.
Assessment PA requiredLargest SMMC plan; in-house UM, dedicated BA fax/form, 5-day determinations, BA VBP.
Assessment PA requiredSpecialty plan for children with chronic conditions; Sunshine machinery, 7-day clock.
Assessment PA requiredBA fully delegated to Carelon — auths AND claims; 30-day data-freshness rule on PAs.
Assessment PA requiredOptum-run since 2/2025: portal-only PA on Provider Express, 2-step auth, 120-day continuity.
Assessment PA requiredWidest channels of the nine (Availity, 24/7 IVR, fax), named BA reps, fee-schedule-linked non-par pay.
Assessment PA requiredBA contracting runs through third-party BSN; universal PA from 7/1/2025 (per plan notices).
Assessment PA requiredAdministers BA in-house on state criteria; a BA QRG exists, but specifics aren't publicly verifiable.
Assessment PA requiredBA fully delegated to Therapy Network of FL — auths AND claims; fastest published turnarounds.
Assessment PA requiredCIDD-focused specialty plan; in-house UM, PA by fax, email, or portal; 120-day continuity honored.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the § 627.6686 Geller Act mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the § 627.6686 Geller Act mandate layer.
No PA on assessmentOptum criteria (BH803ABASCC) + a real FL State Mandates entry: Down syndrome ABA covered.
Assessment PA requiredAutism Auth Request Form, named assessment tools, 6-month dx rule, Kan Be Healthy screen gate.
Assessment PA requiredOptum-run; 6-month dx rule, 40 h/wk plan ceiling, monthly progress reviews, KMAP-first credentialing.
Assessment PA requiredNewest MCO (1/1/2025, absorbed Aetna members); Availity intake, own autism-testing form, thin public policy.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the K.S.A. 40-2,194 mandate layer; no KanCare plan anymore.
Assessment PA requiredEN0499 + autism resource guide + the K.S.A. 40-2,194 mandate layer; no Kansas carve-out.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the K.S.A. 40-2,194 mandate layer.
Assessment PA requiredClosest to the state baseline; OTR-based PA, documentation-heavy NE.CP.BH.105 policy.
Newest MCO (2024); state-baseline rules, Availity intake, quarterly PA-list churn.
ABA carved to Optum since 2017; all autism services need PA, two-step assessment→treatment auth.
Assessment PA requiredCPB 0554 (ABA) + CPB 0648 (ASD) + the Neb. Rev. Stat. § 44-7,106 mandate layer.
Assessment PA requiredEN0499 + autism resource guide + the Neb. Rev. Stat. § 44-7,106 mandate layer.
No PA on assessmentOptum Supplemental Clinical Criteria (BH803ABASCC) + the Neb. Rev. Stat. § 44-7,106 mandate layer.
Assessment PA requiredIdaho’s largest local carrier: no published commercial ABA policy, ABA PA listed for FEP only, Bulletin 18-02 as the coverage floor.
Regence BH18/BH33 with an Idaho-specific form: no assessment PA except FEP, 6-month treatment auths, one standardized assessment required.
No PA on assessmentAetna’s national ABA guide + precert list, on top of Idaho’s Bulletin 18-02 in place of an autism statute.
Assessment PA requiredEvernorth EN0499 + the autism resource guide (no assessment PA) on top of Idaho’s Bulletin 18-02.
No PA on assessmentOptum ABA criteria (no Idaho supplement) + Idaho’s Bulletin 18-02; assessment and treatment both authorized.
Assessment PA requiredCentene IA Health Link plan; CP.BH.104 criteria, six-month auths, 6 hr/day–30 hr/wk soft cap, no ABA for Hawki.
IA Health Link MCO (formerly Amerigroup Iowa); Carelon behind BH, own Clinical UM Guidelines, BH outpatient fax 1-844-451-2826.
IA Health Link MCO; Molina policy MCP 482 (18 months+, >25 hr/wk scrutiny, telehealth for caregiver training/supervision only).
Iowa's Blue plan; ABA policy and auth list are behind a provider login, so the Iowa mandate (no age or dollar caps since 2026) is the public floor.
Aetna national ABA guide + CPB 0554, layered on Iowa's mandate (no age or dollar caps from 1/1/2026).
Assessment PA requiredEvernorth EN0499 criteria; no PA on 97151/97152/0362T; 1–2 hrs supervision per 10 direct; Iowa mandate (no caps from 2026).
No PA on assessmentOptum ABA criteria (1–2 hrs supervision per 10 direct), 32-unit 97153 daily edit, telehealth only for supervision/caregiver training; Iowa mandate.
Assessment PA requiredSoonerSelect MCO. Delivers the SoonerCare ABA benefit; its current documents are blocked to us, and the archived 2025 manual has no ABA-specific rules.
SoonerSelect MCO (Centene) and the only Children’s Specialty Program plan. OK.CP.BH.500 adopts OHCA’s ABA rules; 10% case supervision since 6/30/2026.
Assessment PA requiredSoonerSelect MCO. Follows OHCA’s Part 30; PA on 97151/97153/97155/97156, 24-unit initial assessment, 10% case supervision from 10/12/2026.
Assessment PA requiredCPB 0554 + the ABA medical necessity guide + Nick’s Law (36 O.S. § 6060.21): no age limit, no hour cap on insured plans.
Assessment PA requiredEN0499 + the Evernorth autism resource guide + Nick’s Law: no PA on assessment codes, all ABA codes payable by telehealth.
No PA on assessmentOptum ABA criteria (BH803ABASCC) + Nick’s Law: assessment and treatment both authorized, concurrent 97153/97155 billable.
Assessment PA requiredHCSC Blue plan: MCG criteria since 1/1/2026, phone intake for ABA since April 2026, CPCP011 billing rules, 36-month dx window.
Wayne County PIHP: Access Center 1-800-241-4949, independent evaluation centers, up to 90 days from diagnosis to 1:1 ABA.
Oakland County PIHP: Access (248) 464-6363, in-house diagnostician, MDHHS approval in 12–48 hours, provider link in 7 days.
Macomb County PIHP: 855-99-MCCMH, exam within the past year, 3-year autism enrollment, auth 14+ days ahead, no backdating.
21-county PIHP (12 CMHSPs): no wrong door, outside evaluations accepted if under 3 years old, 14-day UM decisions.
8-county PIHP: screen with M-CHAT or SCQ, ~3-hour evaluation (ADOS-2, ADI-R, DD-CGAS) sent to MDHHS for approval.
Michigan’s Blue plan: ABA regardless of age since 2022, AAEC or independent evaluation, Blue Cross Behavioral Health PA.
Assessment PA requiredMichigan carrier: PA on every ABA code incl. 97151, InterQual criteria, BCBA supervision 1 hr per 15 hrs.
Assessment PA requiredHenry Ford Health’s plan: ABA treatment on HAP’s PA list; criteria behind login; SB 247 7-day/72-hour clock.
CPB 0554 + CPB 0648 + precert on all ABA codes, layered on Michigan’s capped mandate (MCL 500.3406s).
Assessment PA requiredEN0499 + autism resource guide: no PA on assessments, all ABA codes telehealth-eligible, plus Michigan’s capped mandate.
No PA on assessmentOptum ABA criteria (BH803ABASCC): PA required, 1–2 hrs supervision per 10, 97153+97155 concurrent billing, Michigan’s capped mandate.
QUEST Integration plan, Medicaid-only and Hawaii-based. Has its own ABA policy (MP-37, 2026) and requires PA on every ABA code, including 97151.
Assessment PA requiredQUEST Integration plan run by WellCare (Centene). LEAVES QUEST on Dec 31, 2026 — members move to another plan Jan 1, 2027. PA on 97151–97158.
Assessment PA requiredQUEST Integration plan. ABA is managed by Optum (United Behavioral Health) since 2016 — authorizations through Provider Express or fax.
Kaiser Permanente QUEST Integration plan. Integrated model — most care in-house; outside ABA providers need an ARM authorization. ABA rules undocumented publicly.
Hawaii’s Blue Cross Blue Shield licensee. Runs QUEST Integration and commercial lines; ABA is on both precertification lists.
CPB 0554 (ABA) + CPB 0648 (ASD) + Hawaii’s Luke’s Law (under 14, $25K/yr ABA).
Assessment PA requiredEN0499 + autism resource guide + Hawaii’s Luke’s Law (under 14, $25K/yr ABA).
No PA on assessmentUnitedHealthcare commercial in Hawaii — Optum behavioral health, Optum ABA criteria, and Luke’s Law (under 14, $25K/yr ABA).
Largest Medi-Cal plan (2.08M); BHT in-house via the ASD Program, H-codes on form LA5480, no autism dx required.
Assessment PA requiredHealth Net + CalViva Medi-Cal; new policy CA.CP.BH.104 (4/20/2026): 6 h/day–30 h/wk cap, 12-month dx eval, 6-month auths.
Assessment PA requiredRiverside/San Bernardino LI (1.37M); BHT in-house via portal, 6-month units, 2:10 supervision, H0031 = FBA.
Assessment PA requiredOrange County COHS; strict recommendation rules (no LMFT/LCSW/NP alone), Vineland-3 required, PAVE enrollment.
Assessment PA requiredAnthem Medi-Cal in 15 counties + L.A. Care subcontract; ABA precert via Availity or fax; recommendation, not dx.
Assessment PA requiredOwn ABA department + case managers; PA on 97153–97158/0373T; clinical policy stricter than the state APL.
Direct DHCS contract since 2024; entry only through a Kaiser physician referral; KP authorization even when secondary.
Assessment PA requiredCOHS for 24 northern counties; BHT reviewed in-house (not Carelon); TAR for assessment and treatment; ROI with every request.
Assessment PA requiredClosed HMO: BHT only by Kaiser physician referral (NCAL via PDCP/Catalight); 12-month auths; H&S 1374.73 mandate.
Assessment PA requiredMagellan out 1/1/2026 — Blue Shield manages ABA itself; PA on assessment + treatment; BSC3.01; 2:10 supervision ceiling.
Assessment PA requiredPA on every ABA code; fully insured reviewed on AACAP criteria (SB 855), self-funded on licensed MCG B-806-T.
Assessment PA requiredLeaving CA group market (plans end ~2/28/2027); in-house BH Autism Center; CASP criteria; PA via ABA@healthnet.com.
Assessment PA requiredCPB 0554 + ABA MN guide; CA state supplement drops outpatient BH PA on fully insured plans — confirm for ABA.
EN0499 (no CA carve-out) + autism resource guide + the H&S § 1374.73 mandate; no PA on in-network assessment.
No PA on assessmentOptum BH; CASP guidelines posted as CA commercial ABA criteria; State Mandates entry bars IEP/Medicaid offsets.
Assessment PA requiredBH-MCO for 41 PA counties; order + assessment registered in ePortal, ABA treatment by packet PA; 6-month auth cap from 9/17/2026.
Philadelphia’s BH-MCO; ABA needs PA (initial on a written order only); 6-month cap, 2 caregiver goals, 32 BHT units/day since 2025.
HealthChoices BH-MCO, 7 counties; IBHS ABA — 97151 registration (96 units/45 days), 6-month treatment auths via Availity.
HealthChoices BH-MCO, 7 counties; IBHS ABA — 97151 registration in Jiva, 12-month auths, 97153+97155 concurrent billing allowed.
HealthChoices BH-MCO, 11 western counties; IBHS ABA — no PA on the assessment, 180-day treatment auths, Act 62 cover sheet.
Medical Policy V-37 (ASD/ABA) + all ABA codes on the prior-auth list since March 1, 2026, managed in-house by Highmark Behavioral Health.
Assessment PA requiredCentral PA and Lehigh Valley Blue Cross plan: preauthorization for 97151–97158 and 0362T/0373T; ABA was removed from its ASD medical policy in 2023.
Assessment PA requiredSoutheastern PA Blue plan: ABA policy 14.00.03b, in-house Autism Case Management since April 2026 (Magellan out), precert on all ABA codes.
Assessment PA requiredWestern/central PA provider-owned plan: BH run in-house by UPMC Health Plan BHS with Community Care; no published ABA policy — verify by phone.
Central/NE PA plan: MP232 applies the 2017 OMHSAS ABA guideline; in-network ABA for autism no longer needs prior authorization.
No PA on assessmentAetna ABA medical necessity guide + CPB 0648/0554 + BH precertification list, layered on Pennsylvania’s Act 62 mandate.
Assessment PA requiredEvernorth EN0499 + the autism resource guide (no PA on assessment codes), layered on Pennsylvania’s Act 62 mandate.
No PA on assessmentOptum ABA criteria (BH803ABASCC) + Optum’s Pennsylvania Commercial state-mandate entry + Act 62; Optum also runs UHC Community Plan’s PA CHIP ABA network.
Assessment PA requiredAll 852 policy rules from the 266 guides.
As of January 1, 2026, a single form — GR-69017-4 — replaces Aetna's previous ABA precert forms, submitted through Availity's two-step process (precert add + clinical questionnaire) or by phone. The information it demands is exactly what a good intake process should have already collected:
Source ↗Practitioners delivering ABA under Aetna policy need BACB national certification or state behavior-analyst licensure; unlicensed staff work under supervision per practice standards. The diagnosis itself must come from a provider qualified to diagnose within their scope — licensed psychologist, psychiatrist, or physician. CPB 0648 also references intensive-intervention research… full guide →
Source ↗Aetna covers telehealth for 97151, 97153, 97155, 97156, and 97157 (97152 is excluded), billed with GT/95/FR modifiers per its telemedicine payment policy. Notably, Aetna announced it would end ABA telehealth coverage in late 2023 — then rescinded the change within weeks. The lesson for intake: telehealth rules are volatile; verify the current position on every benefits check… full guide →
Source ↗CPB 0554 is Aetna's clinical policy — but self-funded employer plans can carve benefits differently, and state mandates layer on top. Two families with Aetna cards can have materially different ABA benefits. The only safe intake behavior is a live benefits verification on every family: ABA coverage confirmation, deductible status, visit or dollar limits, and the precert path… full guide →
Source ↗With an autism diagnosis on file, an independently licensed provider or BCBA can run assessment codes 97151, 97152, and 0362T without prior authorization (when the plan covers ABA). For intake, that means the sequence can be: verify benefits → book the assessment immediately → build the treatment request from the assessment. No authorization purgatory between first call and… full guide →
Source ↗The treatment PA package is the completed assessment plus treatment plan with Cigna's ABA PA form, which Cigna's autism resource guide encourages providers to submit up to 30 days before or within two weeks after the start of service ("A delay in request may result in a retrospective review"). EN0499 (eff. 5/15/2026) sets the actual retrospective trigger: "A retrospective… full guide →
Source ↗ABA isn't covered when delivered at the same time as another therapy (speech, OT) to the same child — so intake should map the family's existing therapy schedule, not just list it. Only one provider can bill a unit of time, with the standard supervision exceptions. And if a family is transitioning from another ABA agency, overlapping authorization periods require documented… full guide →
Source ↗Assessment and case supervision must come from a BCBA, licensed behavior analyst, or independently licensed clinician with documented ABA training, with direct supervision at the standard 1–2 hours per 10 hours of direct treatment. Evernorth doesn't credential non-licensed staff — RBT services bill under the supervising provider.
Source ↗Step one authorizes the assessment: functional behavior assessment, caregiver interviews, direct observation, record review, baseline skills, and norm-referenced instruments. Step two authorizes treatment based on what the assessment produced. Both run through Provider Express. For most commercial plans without a state-specific carve-out, the standard Optum Supplemental… full guide →
Source ↗Optum authorizes in four clusters: assessment (97151, 97152), direct care (97153, 97154), multi-staff (0362T, 0373T), and QHP services (97155–97158). Units can flex within a cluster without a new authorization — a genuinely useful operational buffer. Concurrent billing is allowed for supervision (97153+97155), group oversight (97154+97155), and parent training alongside direct… full guide →
Source ↗Reviews land every 4–6 months and want progress documented per targeted behavior using the same measurement methods as baseline — mastered-program rates, change scores, updated standardized adaptive measures. Two operational tripwires matter for scheduling and intake: inadequate progress within 6 months requires documented reasons plus treatment modification, and utilization… full guide →
Source ↗Tele-supervision and virtual family training require the provider to be an approved Optum virtual-visits provider with a completed attestation on Provider Express, and the authorization itself must note virtual delivery. Optum frames telehealth as a supplement to — not a replacement for — in-person care.
Source ↗The signal is almost never the front of the card. It is the back — and the fact that the behavioral health phone number is different from the medical one. The Empire Plan is the cleanest illustration in the country. New York State Civil Service names three different administrators for one plan: UnitedHealthcare Insurance Company of New York runs the Medical/Surgical Program,… full guide →
Source ↗Carelon runs what it calls a Provider Digital Front Door built on three surfaces, and the Availity-versus-own-portal question has a precise answer: it is both, linked. Availity Essentials is the multi-payer front end for eligibility, benefits, claim detail, prior-authorization submission and claim status. ProviderConnect and eServices are Carelon’s own portals, and which one… full guide →
Source ↗Carelon publishes two ABA documents in the global (national) section of its forms library, and between them they define the whole submission. The ABA Authorization Request form, effective 1/1/2026, covers initial assessment, initial treatment and concurrent requests on a single sheet — so the assessment itself is an authorized event, not a free first step. It asks for the… full guide →
Source ↗The ABA Provider Treatment Report Guidelines are a fourteen-section specification for the initial packet and a nine-section specification for the concurrent report. Several requirements are the kind that get a resubmission rather than an approval if intake did not gather the inputs:
Source ↗The biggest structural difference: there is no single Carelon ABA medical-necessity policy to read the way you would read a carrier’s clinical policy bulletin. Carelon’s Corporate Quality Medical Management Committee “adopts, reviews, revises, and approves Medical Necessity Criteria per client and regulatory requirements,” and the criteria vary by state, contract and member… full guide →
Source ↗Magellan’s own orientation leads with the warning that matters: “Benefits are not the same for all Magellan members.” It instructs providers to obtain a copy of the member’s card at the first visit, check eligibility on Availity Essentials or by calling the appropriate toll-free number before treating, and re-verify routinely. That phrasing — “the appropriate toll-free number”… full guide →
Source ↗Magellan splits the ABA decision in two: criteria to initiate care for the functional behavior assessment, then criteria to initiate care for direct treatment. The FBA gate is the diagnosis gate — an established and current (within 24 months) DSM-5 autism spectrum diagnosis using a validated assessment tool (ADOS, ADI-R, PEDS, Brigance Diagnostic Inventory of Early Development… full guide →
Source ↗Magellan publishes its intensity bands rather than making you guess them. Focused interventions are generally authorized for 10–25 hours per week of direct treatment, with more than 25 hours approved where medically necessary. Comprehensive ABA of up to 40 hours per week is reserved for multiple targets across most or all developmental domains — typically younger children with… full guide →
Source ↗The sequence Magellan documents is: fax the ABA Request for Initial Authorization together with the diagnostic report; conduct the initial assessment once authorized; then request pre-authorization for additional services on the ABA Treatment Plan / Concurrent Review Template. You may use your own template for the concurrent review provided it contains Magellan’s required… full guide →
Source ↗First: you can read the standard in advance. Magellan combines MCG Behavioral Health Care Guidelines with its own proprietary Magellan Healthcare Guidelines; the Magellan Healthcare Guidelines half is publicly available, while the MCG half is proprietary and obtained by calling the number on the member’s card during a clinical review. The current edition is the 2025–2026… full guide →
Source ↗The signal is a mismatch inside one plan document. Here is a real one: a 2024 employer Summary of Benefits and Coverage for an “Anthem BCBS EPO” plan lists ordinary medical benefits throughout — and then, in the mental health, behavioral health and substance use row, carries its own phone number, its own registration instructions (“login to www.guidanceresources.com, click… full guide →
Source ↗The honest inventory is short. ComPsych publishes network participation requirements, a prospective-provider interest form, and marketing descriptions of its programs. It does not publish an ABA medical-necessity policy, an ABA authorization form, a provider manual, a fee schedule or a payer ID on any page reachable without a login. Its public behavioral health page describes… full guide →
Source ↗Because nothing is published, the routing has to come from the call. A workable script, in order:
Source ↗DHA is explicit that ABA sits outside the medical benefit: occupational therapy, physical therapy, speech therapy, psychological services, psychological testing and prescription drugs are covered by the TRICARE medical benefit, while ABA "is a benefit covered under the ACD," which is "separate from the TRICARE medical benefit." The demonstration is run under 10 U.S.C. § 1092… full guide →
Source ↗Two conditions gate the door: the child must be enrolled in a TRICARE health plan, and must be diagnosed with ASD by an approved diagnosing provider. Humana Military names the covered diagnosis as Autism Spectrum Disorder (F84.0) under DSM-5. Eligible categories include dependents of active duty members, retirees and TRICARE-eligible Reserve Components, member-plus-family… full guide →
Source ↗The referral itself is a defined document, not a note. Per Humana Military it "must include a definitive diagnosis of ASD using the DSM-5 (or current edition) criteria by a PCM or specialized ASD diagnosing provider," the DSM-5 criteria "must be documented in a DHA-approved checklist in the referral," and a validated assessment tool must accompany the referral and confirm the… full guide →
Source ↗This is the ACD’s signature requirement and it has no commercial equivalent. Four instruments are required and the required ones "must be received prior to issuing a treatment authorization." The cadence: the PDDBI at baseline and every six months (the ABA supervisor completes the teacher form); the Vineland-3 at baseline and annually; the SRS-2 parent form at baseline and… full guide →
Source ↗School is the setting that surprises people. DHA states that "ABA services rendered by a behavior technician in the school setting aren’t covered." A Board Certified Behavior Analyst may be authorized where there is a clinically necessary and appropriate goal, subject to clinical necessity review, with pre-authorization required and the contractor approving the goals, which… full guide →
Source ↗The ACD adopted only the Category I codes that transferred from Category III: 97151, 97153, 97155, 97156, 97157 and 97158, plus 99366 and 99368 for medical team conferences. Other codes are not covered. Authorized ABA supervisors and ACSPs bill as outpatient specialty providers; claims must be submitted electronically, EFT enrollment is required, and timely filing is one year… full guide →
Source ↗TRICARE is managed in three regions. Humana Military holds the East; TriWest Healthcare Alliance holds the West under contracts that began Jan. 1, 2025. Six states that had been in the East — Arkansas, Illinois, Louisiana, Oklahoma, Texas and Wisconsin — moved to the West on that date. DHA publishes a ZIP-code lookup on its Regions page rather than a flat state list, so treat… full guide →
Source ↗Four things must be true before anything is authorized: the beneficiary is enrolled in a TRICARE health plan; a TRICARE-authorized ASD diagnosing provider has made a definitive ASD diagnosis; active duty family members are registered for the Extended Care Health Option; and the active duty sponsor is enrolled in their branch’s Exceptional Family Member Program. TriWest may… full guide →
Source ↗TriWest states the rule flatly: all beneficiaries need complete and valid outcome measure scores for ABA service requests to be approved. The PDDBI parent form is due before treatment and every six months; the PDDBI teacher form, completed by the treating ABA supervisor, is required with the first reassessment and every six months after. The Vineland-3 and the SRS-2 are due… full guide →
Source ↗Home (POS 12) and clinic/center (POS 11) Open to all ABA provider types authorized in the treatment plan. Travel to and from a clinic or center is not reimbursable. School (POS 03) Preschool, public, private or homeschool. Only the ABA supervisor may deliver, under CPT 97153. A current IEP must accompany the treatment plan for public or private school, services must be… full guide →
Source ↗TriWest publishes the per-day ceilings: 97153 may not exceed 32 units (8 hours) per day or 160 units (40 hours) per week; 97155 and 97156 may not exceed eight units per day; 97157 and 97158 may not exceed six units per day with a maximum of eight participants per group. 97151 is approved at 32 units for the initial assessment and 24 units per reassessment period, with the… full guide →
Source ↗Cost-shares follow the TRICARE plan type and are charged at specialty outpatient office-visit rates. One copayment covers all ABA services on the same day, there is no annual cap for ABA services, and ABA deductibles and copayments are separate from ECHO cost-sharing. Providers may not bill beneficiaries more than 100% of the posted rates, and network providers may not bill… full guide →
Source ↗CHAMPVA covers the spouse or dependent child of a veteran rated permanently and totally disabled from a service-connected disability; the surviving spouse or child of a veteran who died from a service-connected disability; and the surviving spouse or child of a veteran who was rated permanently and totally disabled from a service-connected disability at the time of death.… full guide →
Source ↗ABA appears twice in the current Guidebook, updated Jan. 1, 2025. It is listed among the services that require pre-authorization, as "Applied behavior analysis (ABA) for treatment only (not the evaluation)." And it has its own line in the Behavioral Health Services benefit table — "Autism – Applied Behavioral Analysis (ABA) requires pre-authorization for treatment only (not… full guide →
Source ↗Where CHAMPVA is the primary payer, ABA carries the standard outpatient split: the patient pays the annual deductible of $50 per individual or $100 per family, then a 25% cost-share, and CHAMPVA pays 75% of the allowable amount. Yearly catastrophic cap protection limits beneficiary cost sharing to $3,000 annually, after which CHAMPVA covers 100% of allowable costs for the rest… full guide →
Source ↗The honest inventory of gaps: the Guidebook does not state an ASD diagnosis requirement or a recency rule; it does not name required assessment instruments or outcome measures; it does not state how long an ABA authorization runs or what a reauthorization requires; it does not define who may render or supervise ABA, or set a supervision ratio; it does not publish per-day unit… full guide →
Source ↗DHA describes USFHP as "a TRICARE Prime option administered by participating nonprofit plans in six service areas in the U.S." Members get most care through a primary care provider in the plan’s own network, and out-of-pocket costs are the same as TRICARE Prime. Two hard limits shape referrals: USFHP members cannot get care at military hospitals and clinics except for… full guide →
Source ↗DHA’s own description of the path names USFHP explicitly: the child’s diagnosing provider "will submit a referral to your regional contractor or US Family Health Plan provider for authorization," and the family then receives an authorization letter for six months of ABA services. The first authorization covers the ABA assessment; the provider completes the assessment and… full guide →
Source ↗Four baseline outcome measures must be completed by the family and the provider team before ABA services can begin: the PDDBI, the Vineland Adaptive Behavior Scales, the Social Responsiveness Scale, and either the Parent Stress Index or the Stress Index for Parents of Adolescents. After baseline, the cadence is mixed — DHA states the four measures must be completed "every six… full guide →
Source ↗The DHA-level setting rules apply: ABA rendered by a behavior technician in a school setting is not covered, while a BCBA may be authorized for a clinically necessary, focused and time-limited goal after clinical necessity review and with the contractor approving the goals. Community settings require checking with the plan first, and families are generally expected to… full guide →
Source ↗Martin’s Point describes its USFHP as "one of six Department of Defense-sponsored TRICARE Prime options nationwide," offering the full TRICARE Prime benefits package to eligible military retirees and their families, certain active-duty family members, and dependents aged 21 to 26 through TRICARE Young Adult. Care is delivered through Martin’s Point’s own civilian provider… full guide →
Source ↗Martin’s Point can authorize ABA under the ACD only where the beneficiary is a dependent of an active duty service member enrolled in the US Family Health Plan and registered for ECHO; a retiree or retiree family member enrolled in TRICARE Prime or TRICARE Select; covered under the Transitional Assistance Management Program; covered under TRICARE For Life; a TRICARE Young… full guide →
Source ↗The initial referral must include a complete assessment, the level of support needed, and the ASD diagnosis. ABA supervisors complete the initial assessment under CPT 97151, and that assessment includes the required outcome measures — the PDDBI, Vineland-3, SRS-2 and either the PSI-4 or the SIPA. Treatment plans are then updated every six months, documenting progress on… full guide →
Source ↗Authorized ABA supervisors Master’s degree or higher in a relevant field, state licensed and/or BACB certified. Assistant behavior analysts Bachelor’s degree with appropriate state licensure or BACB/QABA certification, working under a qualified ABA supervisor. Behavior technicians RBT, ABAT or BCAT certification, operating under the direct supervision of an authorized ABA… full guide →
Source ↗Martin’s Point lists as non-reimbursable: behavior technician training, non-ABA services, travel time unless authorized, academic services and school-based ABA, services provided by family members, and services rendered by a non-authorized ABA provider. Note the tension worth resolving in writing before you schedule anything: the plan’s training lists school-based ABA among… full guide →
Source ↗Coverage applies to Medicaid members under age 21 with a documented DSM-5 ASD diagnosis established by a licensed physician, psychologist, or other qualifying professional using evidence-based tools — per current CMO operationalizations, a comprehensive diagnostic evaluation generally needs at least two instruments (one clinician-administered like ADOS-2 or CARS-2, plus one… full guide →
Source ↗Everything is prior-authorized: one PA for the behavioral assessment, a separate PA for treatment, requested by the enrolled QHCP (licensed physician, psychologist, BCBA-D, or BCBA — BCaBAs and RBTs cannot serve as the QHCP). Treatment authorizations come in 6-month increments; fee-for-service PAs go through the GAMMIS portal, while CMO members follow their plan's process.
Source ↗ABA is not carved out of managed care — most members are in a CMO (CareSource, Peach State, Amerigroup today), and each administers prior auth under its own policy aligned to the DCH manual. December 2024 awards went to CareSource, Humana, Molina, and UnitedHealthcare, but as of this review (8/1/2026) the re-procurement still has not gone live: per DCH's own "Georgia Families… full guide →
Source ↗Georgia reimburses CPT 97151–97158, 0362T, and 0373T in 15-minute units, with practitioner-level modifiers (U1–U5) and setting modifiers — U6 in-clinic, U7 out-of-clinic at a higher rate, GT telehealth. Georgia is unusual in paying different rates by setting, which makes the family's preferred setting (home vs. center) an intake question with direct revenue implications.… full guide →
Source ↗Georgia licensure is new and the deadlines have already passed. HB 412 created O.C.G.A. Title 43, Chapter 7A effective July 1, 2023: behavior analysts and assistant behavior analysts must now be licensed by the Georgia Behavior Analyst Licensing Board (under the Secretary of State), and unlicensed practice carries a $1,000 fine per violation. Every license applicant must clear… full guide →
Source ↗CG-BEH-02 requires all of the following: an ASD diagnosis from a licensed, qualified professional; a person-centered treatment plan with measurable, baseline-anchored goals; a provider licensed or certified per state law; completed functional assessments across motor, language, social, and adaptive domains; and age-appropriate goals targeting the deficits that matter. The… full guide →
Source ↗Georgia's autism mandate (O.C.G.A. § 33-24-59.10) requires state-regulated individual and group plans to cover ASD treatment — including ABA — for individuals 20 and under, with ABA nominally cappable at $35,000/year. Two big caveats every intake team should know: employers with 10 or fewer employees and self-funded ERISA plans are exempt from the state mandate; and federal… full guide →
Source ↗Codes & modifiers 97151–97158 plus 0362T/0373T, with degree-level modifiers (HM/HN/HO). Technician-rendered services must show the supervising BCBA in Box 31 of the CMS-1500. Concurrent billing 97155 alongside 97153 only when technician and QHP are both face-to-face and the QHP is directing. Hour limits Direct treatment ≤40 hours/week; protocol modification up to 2 hours per… full guide →
Source ↗Expect an updated treatment plan every 6 months, interim progress assessment at least every 6 months, standardized developmental assessments at minimum every 2 years, and documented clinically significant progress in adaptive functioning, communication, language, or social skills. Intake sets this clock: the baseline data collected at the start is what every future review gets… full guide →
Source ↗CareSource performs in-house prior authorization and medical review using the Georgia ASD manual plus MCG Health criteria, and requires signed treatment documentation to be submitted prior to claims submission. Because it aligns to the DCH manual, the underlying clinical rules mirror Georgia Medicaid — but the submission path, forms, and timelines are CareSource's own.
Source ↗Effective May 11, 2026, CareSource pays 80% of the Georgia Medicaid fee schedule for covered services — a material change for practices modeling CareSource revenue. It does not change coverage, but it changes the economics of every CareSource authorization.
Source ↗Peach State's PA criteria follow the DCH ASD manual. Hour parameters: no more than 6 hours per day, up to 30 hours per week unless clinically justified; fewer than 20 hours per week for full-time students; protocol modification (97155) at least 2 hours per week or 10% of direct hours. If attendance falls below 80% of authorized hours, justification documentation is required —… full guide →
Source ↗Amerigroup covers ABA under CG-BEH-02, its adaptive behavioral treatment guideline, aligned to the Georgia DCH ASD manual and subject to prior authorization and medical-necessity review. Because the published version is dated 2017/2018 and likely superseded, treat the linked guideline as a starting point and confirm the current requirements on the Amerigroup provider portal… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. The statute exempts employers with 10 or fewer employees, and insurers can seek a one-year opt-out if an… full guide →
Source ↗We checked: Aetna publishes no Georgia-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Georgia-specific answers come from, not a carrier document.
Source ↗Georgia now licenses behavior analysts: HB 412 (2022) created the Georgia Behavior Analyst Licensing Board under the Secretary of State, with licensure built on BCBA certification. Confirm your supervising analysts hold the Georgia license when credentialing with any commercial plan. On rates: Aetna does not publish commercial ABA fee schedules for Georgia (none of the… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. The statute exempts employers with 10 or fewer employees, and insurers can seek a one-year opt-out if an… full guide →
Source ↗We checked: Cigna / Evernorth publishes no Georgia-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Georgia-specific answers come from, not a carrier document.
Source ↗Georgia now licenses behavior analysts: HB 412 (2022) created the Georgia Behavior Analyst Licensing Board under the Secretary of State, with licensure built on BCBA certification. Confirm your supervising analysts hold the Georgia license when credentialing with any commercial plan. On rates: Cigna does not publish commercial ABA fee schedules for Georgia (none of the… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. The statute exempts employers with 10 or fewer employees, and insurers can seek a one-year opt-out if an… full guide →
Source ↗We checked: UnitedHealthcare / Optum publishes no Georgia-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Georgia-specific answers come from, not a carrier document.
Source ↗Georgia now licenses behavior analysts: HB 412 (2022) created the Georgia Behavior Analyst Licensing Board under the Secretary of State, with licensure built on BCBA certification. Confirm your supervising analysts hold the Georgia license when credentialing with any commercial plan. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for Georgia (none of… full guide →
Source ↗RB-BHT is covered for members under 21 with an ASD diagnosis established using a scientifically validated diagnostic tool, via EPSDT — and, less well known, a State Plan Amendment effective July 1, 2021 extends RB-BHT coverage to adults 21 and older as well. For children under three, a provisional diagnosis is accepted at the time services begin, with a definitive diagnosis… full guide →
Source ↗Prior authorization is required for all RB-BHT services — including the assessment. Authorization length is tiered by intensity, which is the detail most often missed: CCP §5.1 gives up to 180 calendar days for treatment plans of 16 hours or fewer per week, but only up to 90 calendar days when the plan exceeds 16 hours a week — so most comprehensive programmes reauthorise… full guide →
Source ↗NC Medicaid publishes RB-BHT rates, and every plan — Standard, Tailored, or LME/MCO — must reimburse at no less than 100% of the state fee schedule unless the provider agrees otherwise, which makes the schedule an effective statewide floor. Current per-15-minute rates (effective 10/1/2025): 97151 $30.56, 97152 $61.73, 97153 $20.81, 97154 $11.37, 97155 $32.22, 97156 $23.70,… full guide →
Source ↗HB 696 (Session Law 2026-1, signed April 30, 2026) rewired NC Medicaid ABA, and the Clinical Coverage Policy 8F rewrite it directed has now been finalized and published, effective August 1, 2026 (Amended Date: August 1, 2026) — confirmed directly from NC Medicaid's live 8F policy page, corroborated by NC Medicaid's August 31, 2026 bulletin restating the new requirements for… full guide →
Source ↗Start with the technician layer, because S.L. 2026-1 changed it: behavior technicians must be certified — RBT (BACB) or ABAT (QABA) — within 120 calendar days of their date of hire (or the agency's first Medicaid enrollment, whichever is later). The finalized CCP 8F, effective August 1, 2026, adds a specific wrinkle for the existing workforce: that same 120-day grace-period… full guide →
Source ↗The provider manual lists RB-BHT among covered behavioral-health services and adopts NC's Clinical Coverage Policies — so the whole clinical picture (PA on everything including assessment, the tiered 180/90-day authorization cadence, LQASP plan reviews) is the CCP 8F baseline covered in the state guide. Submissions run through Availity Essentials' Interactive Care Reviewer;… full guide →
Source ↗Since December 1, 2025, child-welfare-involved members are auto-enrolled in the statewide Children & Families Specialty Plan ("Healthy Blue Care Together"), also operated by Blue Cross NC — a separate plan from standard Healthy Blue with its own member IDs. For intake, this means a foster or kinship placement family saying "we have Healthy Blue" needs one more verification… full guide →
Source ↗The clinical rules are the CCP 8F baseline: PA on all RB-BHT services including the assessment, authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), LQASP treatment-plan reviews at least every six months. AmeriHealth's own layer is a Clinical Coverage Policy Reference Tool mapping to the state policies, a Behavioral Health Utilization… full guide →
Source ↗Clinically, everything is CCP 8F: PA before rendering any RB-BHT service (assessment included), authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), LQASP treatment-plan reviews. Requests go through the provider portal accompanied by the plan's ABA Outpatient Treatment Request Checklist — using it as your internal submission template… full guide →
Source ↗Optum requires an authorization for the ABA assessment that is separate from the treatment authorization — the same structure as Optum's commercial ABA program, run here under NC Medicaid rules. Both submit through the Provider Express secure portal (One Healthcare ID), where the NC ABA quick-reference guide and provider orientation also live; portal support runs at (866)… full guide →
Source ↗WNC.CP.109 mirrors 8F's criteria — under-21 coverage via EPSDT, a validated diagnostic tool, provisional diagnosis under age three with definitive diagnosis within six months, LQASP treatment plans reviewed at least every six months — and defers wholesale to CCP 8F Section 6.0 on provider qualifications. Rather than listing PA'd codes in the policy, WellCare delegates… full guide →
Source ↗Alliance's guidance names the acceptable ASD diagnostic instruments — ADI-R, ADOS-2, CARS-2, and TELE-ASD-PEDS — and explicitly rejects GARS, M-CHAT, and SRS as standalone diagnoses. It's equally specific on the service order: signed by an MD, DO, or licensed psychologist, based on a behavioral/adaptive/functional assessment, dated on or before the service start, valid one… full guide →
Source ↗Alliance publishes its standard rate schedule outright — RB-BHT at the state fee-schedule levels, per 15-minute unit, effective 10/1/2025: 97151 $30.56, 97152 $61.73, 97153 $20.81, 97154 $11.37, 97155 $32.22, 97156 $23.70, 97157 $11.51 (noted as subject to LME/MCO funding). Authorization follows the 8F baseline — PA on everything, with authorization length tiered by intensity… full guide →
Source ↗Every RB-BHT code (97151–97157) requires a TAR — prior authorization — including telephonic and telehealth delivery. The initial request needs the written assessment, diagnosis documentation from a validated tool, and the MD/DO/LP service order; treatment requests add a complete treatment plan signed by the LQASP and the legally responsible person, plus a discharge plan. Under… full guide →
Source ↗The clinical picture is the CCP 8F baseline: PA on all services including the 97151 comprehensive assessment (which Vaya's guidelines designate as LQASP-billed), authorization cycles tiered by intensity (180 calendar days at ≤16 hrs/week, 90 days above), and LQASP treatment-plan reviews. SARs submit through the provider portal and are reviewed by Vaya UM against medical… full guide →
Source ↗Instead of code-by-code authorizations, Partners issues one authorization covering all RB-BHT codes and modifiers: submit via ProAuth entering the base code as the Primary Procedure Code on the Prescreen and selecting the Treatment Type from the dropdown; authorizations are then visible in both ProAuth and Alpha. Operationally this means clinical teams can flex between… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗North Carolina’s mandate (effective July 2016) requires covered health benefit plans to cover “adaptive behavior treatment” — the statutory term; ABA itself isn’t named, but board certified behavior analysts are among the eight authorized provider categories, and treatment must be ordered by a licensed physician or licensed psychologist. Coverage may be limited to individuals… full guide →
Source ↗We checked: Aetna publishes no North Carolina-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where North Carolina-specific answers come from, not a carrier document.
Source ↗North Carolina licenses behavior analysts under the Behavior Analyst Licensure Act (2021), with the NC Behavior Analyst Licensure Board accepting applications since July 2023 — ending the old regime where BCBAs worked under licensed-psychologist supervision. Commercial credentialing now runs on the LBA/LaBA license. On rates: Aetna does not publish commercial ABA fee schedules… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗North Carolina’s mandate (effective July 2016) requires covered health benefit plans to cover “adaptive behavior treatment” — the statutory term; ABA itself isn’t named, but board certified behavior analysts are among the eight authorized provider categories, and treatment must be ordered by a licensed physician or licensed psychologist. Coverage may be limited to individuals… full guide →
Source ↗We checked: Cigna / Evernorth publishes no North Carolina-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where North Carolina-specific answers come from, not a carrier document.
Source ↗North Carolina licenses behavior analysts under the Behavior Analyst Licensure Act (2021), with the NC Behavior Analyst Licensure Board accepting applications since July 2023 — ending the old regime where BCBAs worked under licensed-psychologist supervision. Commercial credentialing now runs on the LBA/LaBA license. On rates: Cigna does not publish commercial ABA fee schedules… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗North Carolina’s mandate (effective July 2016) requires covered health benefit plans to cover “adaptive behavior treatment” — the statutory term; ABA itself isn’t named, but board certified behavior analysts are among the eight authorized provider categories, and treatment must be ordered by a licensed physician or licensed psychologist. Coverage may be limited to individuals… full guide →
Source ↗A family saying “we have UnitedHealthcare” in North Carolina may actually be on the carrier’s Medicaid plan — UnitedHealthcare Community Plan of North Carolina — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Source ↗North Carolina licenses behavior analysts under the Behavior Analyst Licensure Act (2021), with the NC Behavior Analyst Licensure Board accepting applications since July 2023 — ending the old regime where BCBAs worked under licensed-psychologist supervision. Commercial credentialing now runs on the LBA/LaBA license. On rates: UnitedHealthcare does not publish commercial ABA… full guide →
Source ↗IHCP covers ABA when medically necessary for the treatment of ASD, and all ABA services require prior authorization — for fee-for-service through Acentra Health, and through each managed-care entity's own process for MCE members. The clinical bar is specific: an ASD diagnosis supported by a comprehensive diagnostic evaluation (CDE) performed by a doctoral-level HSPP… full guide →
Source ↗Effective April 1, 2026, IHCP covers ABA exclusively through the EPSDT benefit; members 21 and older have a transition window through September 30, 2026, and for dates of service on or after October 1, 2026, IHCP will not authorize or reimburse ABA for members 21+ — making age a first-order intake question. Also effective April 1, 2026: comprehensive ABA (16+ hours/week,… full guide →
Source ↗Indiana publishes its ABA max fees, which makes revenue modeling unusually concrete — including the pain: a 6% reduction on individual ABA codes for dates of service on/after April 1, 2026, and a further 4% on all ABA codes on/after April 1, 2027. Per 15-minute unit: 97153 (technician, U1) $17.06 → $16.04 → $15.39; 97155 (BCBA, U3) $27.63 → $25.97 → $24.93; 97156 (BCBA, U3)… full guide →
Source ↗Indiana is one of the few states where technicians enroll in Medicaid individually. Since December 18, 2024, RBTs enroll with the IHCP as rendering providers (provider type 11, specialty 625 — ABA Therapist RBT), and all RBTs and BCaBAs had to be individually enrolled by April 1, 2025 — each with their own Type 1 NPI, enrolled once and then associated with every group they… full guide →
Source ↗Anthem's stated initial-request requirements are concrete: the PA form, the autism diagnosis coded F84.0, applicable testing results, an intake assessment covering level of functioning, severity, and social/life skills, the treatment plan, and — the one teams miss — the child's daily schedule. Continuation requests need a new PA with an updated treatment plan, developmental… full guide →
Source ↗Members whose care runs through an ACO, PMG, or IPA-contracted group must follow that group's authorization and claims rules rather than Anthem's direct process — worth checking during verification. And because Anthem's guideline hasn't been re-issued since 2021, the 2026 IHCP changes (EPSDT-only, the under-21 cutoff, the 4,000-hour lifetime allocation, mandatory caregiver… full guide →
Source ↗MHS's OTR covers every ABA code and distinguishes Focused vs. Comprehensive treatment and Initial vs. Concurrent requests. The formal ASD diagnosis must name the standardized tool used — ADI-R, ADOS, CARS-2, M-CHAT, ASSQ, or GARS — with the administration date, score, and diagnosing provider. The treatment episode must also commit to at least one outcome instrument (VB-MAPP,… full guide →
Source ↗Submissions go through the CareSource Provider Portal (its stated preference, with "immediate approvals" possible for clean requests), by phone to utilization management at (844) 607-2831, or by fax to (844) 432-8924 — using the Indiana Medicaid universal PA request form; there is no CareSource-specific ABA form. The clinical package mirrors IHCP: ASD diagnosis from a licensed… full guide →
Source ↗MM-0900 is no longer the operative document, but the rules it codified track state policy and remain good intake heuristics: only one lead analyst and one ABA agency per member at a time (transitions need coordination, not overlap); no coverage for services rendered by family or household members; and no coverage for shadow/paraprofessional/companion support or primarily… full guide →
Source ↗The Behavioral Health Reference Guide lists ABA codes 97151–97158, 0362T, and 0373T as PA-required across both Hoosier Healthwise and HIP, with treatment requests routed to the medical management department for the member's delivery system. There's no MDwise-specific ABA form — the IHCP universal PA form plus an outpatient treatment request does the work. Because the… full guide →
Source ↗Optum was selected by UHC Community Plan to build and manage the Indiana ABA network, which means ABA providers must be in the Optum network — credentialed separately from UHC's medical side — and enrolled with Indiana Medicaid before joining. Behavioral-health PA runs by phone at (877) 610-9785 (or the number on the member's card), through Provider Express ("Auth Request"),… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Indiana’s mandate (2001) was the first autism insurance mandate in the country, and it remains one of the strongest: group accident and sickness policies must cover ASD treatment prescribed by the treating physician under a treatment plan, with no age limits and no dollar, visit, or hour caps — and cost-sharing no less favorable than for physical illness generally.… full guide →
Source ↗We checked: Aetna publishes no Indiana-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Indiana-specific answers come from, not a carrier document.
Source ↗Indiana began licensing behavior analysts in May 2025 (IC 25-8.5, via the Professional Licensing Agency’s Behavior Analyst Committee), built on current BCBA/BCaBA certification with biennial renewal. Expect commercial payers to fold the LBA license into credentialing requirements as it phases in. On rates: Aetna does not publish commercial ABA fee schedules for Indiana (none… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Indiana’s mandate (2001) was the first autism insurance mandate in the country, and it remains one of the strongest: group accident and sickness policies must cover ASD treatment prescribed by the treating physician under a treatment plan, with no age limits and no dollar, visit, or hour caps — and cost-sharing no less favorable than for physical illness generally.… full guide →
Source ↗We checked: Cigna / Evernorth publishes no Indiana-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Indiana-specific answers come from, not a carrier document.
Source ↗Indiana began licensing behavior analysts in May 2025 (IC 25-8.5, via the Professional Licensing Agency’s Behavior Analyst Committee), built on current BCBA/BCaBA certification with biennial renewal. Expect commercial payers to fold the LBA license into credentialing requirements as it phases in. On rates: Cigna does not publish commercial ABA fee schedules for Indiana (none… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Indiana’s mandate (2001) was the first autism insurance mandate in the country, and it remains one of the strongest: group accident and sickness policies must cover ASD treatment prescribed by the treating physician under a treatment plan, with no age limits and no dollar, visit, or hour caps — and cost-sharing no less favorable than for physical illness generally.… full guide →
Source ↗Indiana is one of the states with its own entry in Optum’s ABA State Mandates supplemental criteria: for Indiana members, services are recognized as intensive and may be provided daily, and the document explicitly disclaims any quantitative benefit limits implied by its guidelines — intensity keys to the individualized treatment plan. That’s useful language to cite when a… full guide →
Source ↗A family saying “we have UnitedHealthcare” in Indiana may actually be on the carrier’s Medicaid plan — UnitedHealthcare Community Plan of Indiana — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Source ↗Indiana began licensing behavior analysts in May 2025 (IC 25-8.5, via the Professional Licensing Agency’s Behavior Analyst Committee), built on current BCBA/BCaBA certification with biennial renewal. Expect commercial payers to fold the LBA license into credentialing requirements as it phases in. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for… full guide →
Source ↗Section 4 is the operative one: "An accident and sickness insurance policy that is issued on a group basis must provide coverage for the treatment of an autism spectrum disorder of an insured. Coverage provided under this section is limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan." Section 5 requires insurers… full guide →
Source ↗Anthem's Indiana commercial entity is Anthem Insurance Companies, Inc., and Indiana shares one precertification list with Kentucky, Missouri, Ohio and Wisconsin. That list includes applied behavioral analysis in the behavioral health services requiring preapproval for OH, IN and KY Blues products, with the responsible party given as Anthem, and carries a separate "Treatment… full guide →
Source ↗Any guide still saying Indiana has no behavior-analyst licensure is out of date. The Indiana Professional Licensing Agency runs a Behavior Analyst Licensing Board issuing Licensed Behavior Analyst and Licensed Assistant Behavior Analyst credentials, and its own site records the milestone: applications went live on May 13, 2025. The statute (IC 25-8.5) was enacted in 2021 and… full guide →
Source ↗Anthem told Indiana commercial providers that "effective June 1, 2024, Anthem will transition from CG-BEH-02 (Adaptive Behavioral Treatment) and MCG W0153 (Behavioral Health Care Applied Behavioral Analysis), to MCG B-806-T Behavioral Health Care Applied Behavioral Analysis (Original MCG Guideline), for medical necessity/clinical appropriateness reviews." The notice was… full guide →
Source ↗Anthem has moved ABA reimbursement onto weekly approved units rather than total authorized units. Claims should reflect the units rendered within each week, up to the weekly medically necessary limit as approved by prior approval; claims submitted with units exceeding the weekly limit are ineligible for reimbursement and get adjusted. Existing requests and claims, including… full guide →
Source ↗DMAS requires no service authorization for the assessment codes — 97151, 97152, and 0362T — a fact confirmed both in the Mental Health Services manual's Appendix D and in the fee file's own PA flags. For intake, that means the sequence can be: verify eligibility → book the assessment immediately → build the treatment request from the assessment. One post-pandemic constraint:… full guide →
Source ↗All treatment hours require service authorization with a predetermined number of units for each treatment procedure code. Effective for dates of service October 15, 2025 and later, requests — fee-for-service and every Cardinal Care MCO alike — must itemize units per ABA CPT code on the new DMAS standardized preservice form (no more bundling under 97155), so intake and clinical… full guide →
Source ↗Effective January 1, 2026, the CMS Interoperability and Prior Authorization Final Rule imposes hard decision deadlines on prior-authorization requests — covering behavioral health/ABA — for DMAS FFS and every Cardinal Care MCO alike: 72 hours for expedited requests, and 7 calendar days for standard requests. The 7-day standard clock can extend to 14 days only if the member or… full guide →
Source ↗Virginia's fee schedule pays by practitioner licensure tier, flagged with modifiers: no modifier = technician, HN = Licensed Assistant Behavior Analyst (LABA), TF = LMHP, HO = Licensed Behavior Analyst (LBA). Per 15-minute unit (effective 12/1/2021 and still current in the July 2026 fee file): 97153 direct treatment pays $15.00 at the technician tier, $23.48 LABA, $39.40 LMHP,… full guide →
Source ↗Cardinal Care is the unified brand for Virginia Medicaid managed care, and a new single managed-care contract took effect July 1, 2025 — the same date Molina exited Virginia Medicaid (contract terminated 6/30/2025) and Humana Healthy Horizons entered, absorbing Molina's members. The five active MCOs — Aetna Better Health, Anthem HealthKeepers Plus, Humana Healthy Horizons,… full guide →
Source ↗Virginia does not require the RBT credential. Technician-level Medicaid ABA is delivered by unlicensed personnel working under a Licensed Behavior Analyst (LBA) or Licensed Assistant Behavior Analyst (LABA) per the Board of Medicine's supervision rules (18VAC85-150), and there is no state technician registry — DMAS classifies staff simply as licensed or unlicensed. Scope… full guide →
Source ↗Treatment requests use the DMAS standardized MHS ABA initial and continued-stay forms, submitted through Availity (the plan's preferred channel) or by fax to (833) 757-1583, with the DMAS rules — per-code units, the 20-hour activity-schedule threshold — applying as everywhere in Cardinal Care. Details that bounce submissions: signature-font e-signatures are rejected on SA… full guide →
Source ↗Enroll with DMAS through the PRSS portal and select Aetna, then email the plan's provider-relations team (AetnaBetterHealth-VAProviderRelations@Aetna.com) to trigger credentialing. Telehealth follows state policy (GT modifier). Timely filing runs 365 days, EDI payer ID 128VA.
Source ↗Anthem's February 2023 provider bulletin publishes the full ABA code/modifier/place-of-service grid: no service authorization on 97151, 97152, and 0362T; SA required on 97153–97158 and 0373T; GT telehealth combinations payable on the assessment, direct-treatment, and family-training codes; and school as an allowed place of service (POS 03) for 97151, 97155, and 97156 — useful… full guide →
Source ↗Behavioral-health authorizations submit digitally through Availity Essentials' Interactive Care Reviewer; provider services runs at (800) 901-0020. The DMAS rules apply unchanged: per-code unit requests since October 2025, the ≥20-hours/week activity-schedule requirement (stated on Anthem's own form), and the under-21 EPSDT scope in effect since December 2021.
Source ↗Former Molina members transitioned to Humana automatically on July 1, 2025 (with a 90-day plan-change window through September 30, 2025), and existing service authorizations were honored for at least 30 days past the transition. By now any Molina-era authorization has cycled through Humana's own process — but member cards, portal registrations, and stale directory listings can… full guide →
Source ↗Humana's Virginia PA and notification list (effective 7/1/2025) requires prior authorization on 97153–97158 and 0373T, with 97151 and 97152 correctly PA-free per the DMAS baseline. The quirk: the list also flags 0362T — a code DMAS treats as an authorization-free assessment code — as PA-required. If your assessments use 0362T for Humana members, request the authorization… full guide →
Source ↗Treatment requests use the DMAS preservice service-authorization form — the units-per-code version Sentara posted for dates of service September 1, 2025 and after — plus the matching continued-stay form. The form itself embeds the DMAS rules: units requested per CPT code, and the 20-hours/80-units threshold that triggers the individualized activity schedule. Its worked example… full guide →
Source ↗The 2026 provider manual is explicit that all mental-health services — ABA included — require registration or authorization using a DMAS service-specific form, which keeps the clinical criteria identical statewide; Optum's national ABA guideline does not override the Virginia rules. What Optum changes is the plumbing: the Cardinal Care PA requirements list (effective March… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Virginia’s mandate covers individual and group policies and HMO plans, and since January 1, 2020 it applies at any age — the old age caps were removed by 2019’s HB 2577. ABA is subject to an annual maximum benefit of $35,000 unless the insurer elects more (still in the current statute), must be provided or supervised by a behavior analyst licensed by the Board of Medicine, and… full guide →
Source ↗A family saying “we have Aetna” in Virginia may actually be on the carrier’s Medicaid plan — Aetna Better Health of Virginia — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Source ↗Virginia requires a Board of Medicine license to practice as a behavior analyst (Va. Code § 54.1-2957.16, built on BACB certification) — and the mandate itself conditions ABA coverage on delivery or supervision by a licensed behavior analyst, so licensure is a coverage requirement, not just a credentialing one. On rates: Aetna does not publish commercial ABA fee schedules for… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Virginia’s mandate covers individual and group policies and HMO plans, and since January 1, 2020 it applies at any age — the old age caps were removed by 2019’s HB 2577. ABA is subject to an annual maximum benefit of $35,000 unless the insurer elects more (still in the current statute), must be provided or supervised by a behavior analyst licensed by the Board of Medicine, and… full guide →
Source ↗The current EN0499 states verbatim that Virginia fully-insured business is not subject to the policy. For fully-insured Cigna members in Virginia, coverage terms come from the plan document and the state mandate — not Cigna’s national IBI criteria — while self-funded (ASO) plans still follow EN0499. Practically: for a Virginia Cigna family, don’t assume the no-assessment-PA… full guide →
Source ↗Virginia requires a Board of Medicine license to practice as a behavior analyst (Va. Code § 54.1-2957.16, built on BACB certification) — and the mandate itself conditions ABA coverage on delivery or supervision by a licensed behavior analyst, so licensure is a coverage requirement, not just a credentialing one. On rates: Cigna does not publish commercial ABA fee schedules for… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Virginia’s mandate covers individual and group policies and HMO plans, and since January 1, 2020 it applies at any age — the old age caps were removed by 2019’s HB 2577. ABA is subject to an annual maximum benefit of $35,000 unless the insurer elects more (still in the current statute), must be provided or supervised by a behavior analyst licensed by the Board of Medicine, and… full guide →
Source ↗Virginia has its own entry in Optum’s ABA State Mandates supplemental criteria: for Virginia commercial fully-insured HMO and insurance plans (effective July 2022), Optum adopts the Virginia statutory definitions of “autism spectrum disorder” and “medically necessary” in place of its standard criteria — so for fully-insured members, the statute’s definitions, not Optum’s… full guide →
Source ↗A family saying “we have UnitedHealthcare” in Virginia may actually be on the carrier’s Medicaid plan — UnitedHealthcare Community Plan of Virginia — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Source ↗Virginia requires a Board of Medicine license to practice as a behavior analyst (Va. Code § 54.1-2957.16, built on BACB certification) — and the mandate itself conditions ABA coverage on delivery or supervision by a licensed behavior analyst, so licensure is a coverage requirement, not just a credentialing one. On rates: UnitedHealthcare does not publish commercial ABA fee… full guide →
Source ↗Both Virginia lists carry a responsible-party column, and for all ten ABA codes it reads Anthem. Carelon Medical Benefits Management appears throughout both documents — it owns imaging, genetic testing, musculoskeletal, oncology and the rehabilitative-therapy codes such as 97140, 97150 and 97161 — but never an ABA code. Carelon Behavioral Health does not appear in either list… full guide →
Source ↗Virginia's mandate binds insurers issuing expense-incurred hospital, medical and surgical or major medical policies, corporations issuing subscription contracts, and HMOs, and it extends to state employee coverage and to local-government, teacher and retiree coverage. Since January 1, 2020 it applies to individuals "of any age" — note that the change removed not just the upper… full guide →
Source ↗An independent prescriber Covered ABA is "applied behavior analysis when provided or supervised by a board certified behavior analyst who shall be licensed by the Board of Medicine. The prescribing practitioner shall be independent of the provider of applied behavior analysis." A referral written by a clinician inside your own practice can fail this test — capture who ordered… full guide →
Source ↗Virginia makes it unlawful to practise as, or hold oneself out as, a behavior analyst or assistant behavior analyst without a licence from the Board of Medicine, which issues the titles Licensed Behavior Analyst and Licensed Assistant Behavior Analyst. Licensure is layered on top of national certification: the application requires documentation of current BACB certification as… full guide →
Source ↗Anthem's Virginia entity is Anthem Health Plans of Virginia, Inc., and its own boilerplate is precise about geography: Anthem and its affiliate HealthKeepers, Inc. "serve all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123." Anthem's commercial prior-authorization page puts it more colloquially — Virginia "excluding the… full guide →
Source ↗Children on TennCare receive services through EPSDT, which requires coverage of medically necessary services — including ABA — for members under 21. There is no annual benefit limit on ABA under TennCare, and the unified MCO program sets no fixed weekly-hour cap either: requested hours are justified clinically using a severity/unit guide (levels 1–3 per domain), in 15-minute… full guide →
Source ↗TennCare and its three MCOs jointly issued a single "ABA Provider Requirements and Program Description" (2024) and a universal "Request for Applied Behavior Analysis" form carrying all three MCOs' logos, fax numbers, and portals (current version January 2026). The shared baseline: an ASD or other qualifying DSM-5-TR diagnosis by a qualified professional with the diagnostic… full guide →
Source ↗A licensed provider must prescribe the service, and coverage is always subject to medical necessity, with prior authorization required for both the assessment and treatment. Authorizations run in 6-month (26-week) periods; continuation requires documented progress against goals, current severity levels, requested hours per code, and parent-training (97156) volume. Tennessee… full guide →
Source ↗Unlike most state Medicaid programs, TennCare publishes no ABA fee schedule — each "at-risk" MCO negotiates its own provider contracts and maintains its own rates. A February 2026 multistate comparison of Medicaid ABA reimbursement leaves every Tennessee cell blank for exactly this reason. For practices modeling TennCare revenue, the only source of truth is your own MCO… full guide →
Source ↗Tennessee does not license or register behavior technicians — the tri-MCO program description is the binding document, and it requires that RBTs and their supervising BCBAs "comply with ALL of the current BACB requirements for credentialing, ethics, competency, supervision, and maintenance of the RBT credential." Unlicensed staff deliver ABA under the extended authority and… full guide →
Source ↗Submissions run through Availity (or via provider.bcbst.com), with fax as the fallback — (800) 292-5311 for BlueCare/TennCareSelect and (800) 851-2491 for CoverKids. The assessment PA uses the universal tri-MCO request form with the diagnostic report and doctor's order attached; treatment requests add BlueCare's supplemental "Initiation and Continuation of ABA Therapy" form… full guide →
Source ↗Authorized ABA hours are not inclusive of other services — the form explicitly separates OT/PT — so map the family's full therapy schedule without fear of crowding out the ABA request. Standard (non-urgent) authorization decisions are due within 7 calendar days: BlueCare's July 2026 manual commits to "State-established timeframes that may not exceed 7 calendar days following… full guide →
Source ↗UHC's Level of Care Guidelines require a comprehensive clinical evaluation by a Tennessee-licensed clinician and a physician order or script recommending ABA before initiation — the most explicit ordering requirement among the TennCare MCOs. Comprehensive programs above 20 hours/week "should generally only be considered" when the member has multiple needs, is within roughly… full guide →
Source ↗Requests use the universal tri-MCO form, submitted via Provider Express, fax (877) 217-6068, or secure email (tn_medicaid_aba@uhc.com); the ABA line is (800) 690-1606. Authorization lengths are set per individual need (the universal form models 26-week periods), with reassessment at the end of each authorized period. Two rules to design intake around: caregiver training is… full guide →
Source ↗Submissions go through Availity — Wellpoint's stated preferred workflow is to complete the universal tri-MCO ABA request form and attach it as the clinical documentation in the Interactive Care Reviewer; fax fallback is (866) 920-6006 (the form also lists (888) 881-6309). The assessment request needs an MD order or a licensed treating provider's recommendation. Treatment… full guide →
Source ↗Wellpoint publishes named regional ABA contacts (West, Middle, and East Tennessee plus a statewide UM manager and behavioral-health liaison) with direct phones and emails in its tri-MCO update materials; provider services runs at (833) 731-2154. For an intake team, a saved contact sheet per region turns authorization questions from portal tickets into phone calls.
Source ↗The state's own contract text describes it plainly: "The Contractor shall operate under and market the services delivered via the prepaid Inpatient Health Plan (PIHP) as 'TennCare Select.'" That PIHP agreement (Edison Contract ID 83332, term 1/1/2025–12/31/2027) is separate from BlueCare Tennessee's standard MCO contract, though both sit with Volunteer State Health Plan.… full guide →
Source ↗TennCare assigns — rather than lets members pick — enrollees who fall into defined categories: children under 21 who are SSI-eligible; children in DCS (foster care) custody and those transitioning out of custody (branded "SelectKids"); enrollees receiving services in an institution or an HCBS 1915(c) waiver for intellectual disabilities; enrollees living out-of-state;… full guide →
Source ↗TennCare's own Managed Care Program Annual Report (MCPAR), submitted to CMS on 6/29/2025 for reporting period CY2024, lists average monthly enrollment across TennCare's four managed-care products: Wellpoint Tennessee 438,735; BlueCare Tennessee 552,517; UnitedHealthcare Community Plan 439,049; and TennCare Select 37,095 — about 2.5% of statewide TennCare enrollment. That's the… full guide →
Source ↗ABA requests use the shared tri-MCO universal request form, submitted through Availity for in-state providers or Cohere for out-of-state providers; PA questions route to (423) 535-5717, option 2. Two BCBST-hosted ABA forms — an "ABA Therapy Services Assessment Request Form" and an "Initiation and Continuation of ABA Therapy Form" (the latter confirming the 26-week/6-month… full guide →
Source ↗TennCare Select is the exclusive administrator of SelectCommunity and Katie Beckett Part A, and shares CHOICES/ECF CHOICES LTSS administration with BlueCare — the MLTSS Provider Manual states plainly that "all BlueCare/TennCare Select billing guidelines apply" for these populations. That matters for staffing: TennCare's Aligned Background Check Protocol (effective July 1,… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Tennessee’s statute is the weakest of the states we cover — it’s a parity rule, not an ABA mandate. For insureds under 12, plans that cover neurological disorders must provide ASD benefits at least as comprehensive, with cost-sharing no more stringent; ABA is never named, and the statute explicitly doesn’t expand the type or scope of treatment beyond other neurological… full guide →
Source ↗We checked: Aetna publishes no Tennessee-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Tennessee-specific answers come from, not a carrier document.
Source ↗Tennessee requires the Licensed Behavior Analyst (LBA) credential under Tenn. Code Ann. §§ 63-11-301 through 63-11-311, administered by the Applied Behavior Analyst Licensing Committee at the Department of Health — the same licensure gate that governs TennCare work applies on the commercial side. On rates: Aetna does not publish commercial ABA fee schedules for Tennessee (none… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Tennessee’s statute is the weakest of the states we cover — it’s a parity rule, not an ABA mandate. For insureds under 12, plans that cover neurological disorders must provide ASD benefits at least as comprehensive, with cost-sharing no more stringent; ABA is never named, and the statute explicitly doesn’t expand the type or scope of treatment beyond other neurological… full guide →
Source ↗We checked: Cigna / Evernorth publishes no Tennessee-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Tennessee-specific answers come from, not a carrier document.
Source ↗Tennessee requires the Licensed Behavior Analyst (LBA) credential under Tenn. Code Ann. §§ 63-11-301 through 63-11-311, administered by the Applied Behavior Analyst Licensing Committee at the Department of Health — the same licensure gate that governs TennCare work applies on the commercial side. On rates: Cigna does not publish commercial ABA fee schedules for Tennessee (none… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Tennessee’s statute is the weakest of the states we cover — it’s a parity rule, not an ABA mandate. For insureds under 12, plans that cover neurological disorders must provide ASD benefits at least as comprehensive, with cost-sharing no more stringent; ABA is never named, and the statute explicitly doesn’t expand the type or scope of treatment beyond other neurological… full guide →
Source ↗A family saying “we have UnitedHealthcare” in Tennessee may actually be on the carrier’s Medicaid plan — UnitedHealthcare Community Plan of Tennessee — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Source ↗Tennessee requires the Licensed Behavior Analyst (LBA) credential under Tenn. Code Ann. §§ 63-11-301 through 63-11-311, administered by the Applied Behavior Analyst Licensing Committee at the Department of Health — the same licensure gate that governs TennCare work applies on the commercial side. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for… full guide →
Source ↗OAC rule 5160-34-02 covers adaptive behavior services for the assessment and treatment of ASD, with prior authorization required for all covered ABA codes at both initial and ongoing stages and medical-necessity review at baseline and at least every six months. The ASD diagnosis must come from a documented comprehensive diagnostic evaluation by a licensed physician,… full guide →
Source ↗ODM's ABA fee schedule pays per 15-minute unit by practitioner tier. Current maximum payment amounts: 97151 assessment $30.49 at the independent-practitioner tier (COBA/BCBA/BCBA-D) and $22.67 at the BCaBA tier; 97153 direct treatment $16.04 (RBT tier); 97155 protocol modification $27.28 / $20.63; 97156 family training $30.09 / $22.37; group codes and 0362T/0373T ($33.54) have… full guide →
Source ↗A recurring point of confusion in Ohio: OhioRISE — the Aetna-run specialty plan for youth with complex behavioral-health needs — does not cover ABA. ODM's Mixed Services Protocol states explicitly that claims for ABA services (97151–97158, 0362T, 0373T) for ASD are the responsibility of the member's Medicaid MCO or fee-for-service, even when the youth is enrolled in OhioRISE.… full guide →
Source ↗Ohio layers no separate technician license or state registry on top of the BACB — behavior technicians are RBTs, so the BACB's own bar is the employee-level floor: applicants must be at least 18 with a high-school education, complete the 40-hour training and initial competency assessment, and pass both a criminal background check and an abuse-registry check no more than 180… full guide →
Source ↗Where the state rule accepts any licensed clinician qualified to diagnose autism, MM-0028 restricts the diagnosis to a child/adolescent psychiatrist, psychologist, child neurologist, or developmental pediatrician, using a standardized instrument — ADOS, ADI-R, or CARS-2. If the evaluation is more than 24 months old, a provider letter documenting DSM symptoms within the past… full guide →
Source ↗All ABA services get medical-necessity review at baseline and every 6 months, with continuation requests documenting progress against baseline using the same measurement tools. Behavioral assessments should generally not exceed 6–10 hours per 6-month period without justification. The 9/1/2026 MM-0028 update adds two operational details: a continuation request filed after a… full guide →
Source ↗Treatment PA (97153–97158) runs through Buckeye's Autism Services Prior Authorization Request Form, which wants the individual diagnostic interview or FBA, objective testing results, a description of coordination with other services, the proposed schedule with rendering provider type per session, a parent-training plan, and a copy of the IEP or IFSP. The form also requires an… full guide →
Source ↗CP.BH.104 sets the numbers: treatment should not exceed 6 hours/day and 30 hours/week without detailed clinical justification (severity or escalation criteria, with BCBA and guardian signatures), and the policy expects under 20 hours/week for children attending school full-time — comprehensive ABA is framed as 30–40 hours/week for the cases that warrant it. Protocol… full guide →
Source ↗Clinically, expect the OAC 5160-34 baseline: PA on covered ABA codes, DSM-5-TR diagnosis via comprehensive evaluation, and 6-month medical-necessity reviews. Operationally, the January 2026 change matters most — all prior authorization requests go through Availity Essentials, with fax submissions no longer accepted in Ohio. Because Molina's public site is inaccessible to… full guide →
Source ↗Anthem's Ohio Medicaid Clinical UM Guidelines list confirms CG-BEH-02 (and CG-BEH-15 for activity therapy) as the adopted criteria for adaptive behavioral treatment, layered on the OAC 5160-34 baseline. The CG-BEH-02 family of guidelines carries the familiar Anthem parameters — total requested treatment at or under 40 hours/week, protocol modification around 2 hours per 10… full guide →
Source ↗The supplemental criteria require a DSM-5-TR diagnosis from a state-licensed physician, psychologist, or qualified clinician using at least one validated screening tool plus one formal diagnostic instrument (ADOS, ADI-R, or DISCO). There's no numeric hour cap — requested hours must be justified by impairment, severity, and history — but continued-treatment reviews specifically… full guide →
Source ↗The clinical baseline is the state rule: PA on ABA services, DSM-5-TR diagnosis via comprehensive evaluation, 6-month review cycles. Authorization requests flow through the Jiva UM system via NaviNet, with UM at (833) 735-7700 and a standard decision due “no later than seven calendar days following receipt of the request for service” under OAC 5160-26-03.1 (effective 1/1/2026)… full guide →
Source ↗The PA and notification list is unambiguous: "Applied behavioral analysis (ABA) therapy" covers 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, and 0373T — so unlike Buckeye (or the DMAS-style structures elsewhere), the assessment itself needs authorization before the first appointment, and intake should sequence accordingly. Services rendered without PA are… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Ohio’s mandate (HB 463, 2017; R.C. 3923.84, with § 1751.84 for HMOs) sets service floors for insureds under age 14 rather than caps: at least 20 hours/week of “clinical therapeutic intervention” — explicitly defined to include applied behavior analysis — plus 20 visits/year each for speech and OT and 30 outpatient mental-health visits/year. Mandated ABA must be provided by or… full guide →
Source ↗We checked: Aetna publishes no Ohio-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Ohio-specific answers come from, not a carrier document.
Source ↗Ohio’s COBA certificate (ORC Chapter 4783, Ohio Board of Psychology, with a direct BCBA pathway) is baked into the mandate itself — R.C. 3923.84 conditions mandated ABA on COBA-supervised delivery — so COBA status is a commercial coverage requirement in Ohio, not just a Medicaid credentialing detail. On rates: Aetna does not publish commercial ABA fee schedules for Ohio (none… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Ohio’s mandate (HB 463, 2017; R.C. 3923.84, with § 1751.84 for HMOs) sets service floors for insureds under age 14 rather than caps: at least 20 hours/week of “clinical therapeutic intervention” — explicitly defined to include applied behavior analysis — plus 20 visits/year each for speech and OT and 30 outpatient mental-health visits/year. Mandated ABA must be provided by or… full guide →
Source ↗We checked: Cigna / Evernorth publishes no Ohio-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Ohio-specific answers come from, not a carrier document.
Source ↗Ohio’s COBA certificate (ORC Chapter 4783, Ohio Board of Psychology, with a direct BCBA pathway) is baked into the mandate itself — R.C. 3923.84 conditions mandated ABA on COBA-supervised delivery — so COBA status is a commercial coverage requirement in Ohio, not just a Medicaid credentialing detail. On rates: Cigna does not publish commercial ABA fee schedules for Ohio (none… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Ohio’s mandate (HB 463, 2017; R.C. 3923.84, with § 1751.84 for HMOs) sets service floors for insureds under age 14 rather than caps: at least 20 hours/week of “clinical therapeutic intervention” — explicitly defined to include applied behavior analysis — plus 20 visits/year each for speech and OT and 30 outpatient mental-health visits/year. Mandated ABA must be provided by or… full guide →
Source ↗Ohio has its own entries in Optum’s ABA State Mandates supplemental criteria: for Ohio fully-insured members (effective March 2025), ASD screening, diagnosis, and treatment may also be performed, prescribed, or ordered by clinical nurse specialists and certified nurse practitioners — mirroring the 2025 amendment to the state mandate and widening who can generate a qualifying… full guide →
Source ↗A family saying “we have UnitedHealthcare” in Ohio may actually be on the carrier’s Medicaid plan — UnitedHealthcare Community Plan of Ohio — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Source ↗Ohio’s COBA certificate (ORC Chapter 4783, Ohio Board of Psychology, with a direct BCBA pathway) is baked into the mandate itself — R.C. 3923.84 conditions mandated ABA on COBA-supervised delivery — so COBA status is a commercial coverage requirement in Ohio, not just a Medicaid credentialing detail. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for… full guide →
Source ↗R.C. 3923.84 requires each individual and group sickness and accident policy delivered, issued for delivery or renewed in Ohio to cover the screening, diagnosis and treatment of autism spectrum disorder. R.C. 1751.84 is its twin for health insuring corporations, with identical substance. What the statute then sets out are minimums for an insured under the age of fourteen:… full guide →
Source ↗Unusually, Ohio writes prior authorization into the mandate rather than leaving it to the carrier. Subsection (C)(2) says a policy "shall stipulate that coverage provided under this section be contingent upon both of the following: (a) The covered individual receiving prior authorization for the services in question; (b) The services in question being prescribed or ordered by… full guide →
Source ↗Anthem's Ohio commercial entity is Community Insurance Company, and Ohio shares one precertification list with Indiana, Kentucky, Missouri and Wisconsin. Under behavioral health services that list includes, for OH, IN and KY Blues products, applied behavioral analysis among the services requiring preapproval — with the responsible party given as Anthem. A separate row reads… full guide →
Source ↗Ohio does not license "behavior analysts" — it certifies Certified Ohio Behavior Analysts through the State Board of Psychology. Applicants must demonstrate current BACB certification as a board certified behavior analyst, or completion of equivalent requirements plus a psychometrically valid examination from a nationally accredited credentialing organization. R.C. 4783.02… full guide →
Source ↗Effective January 1, 2026, Anthem reimburses ABA in Ohio on weekly approved units rather than total authorized units. Claims should reflect units rendered within each week up to the weekly medically necessary limit approved by prior approval; units above it are ineligible for reimbursement and will be adjusted. The affected codes are the full set — 97151, 97152, 0362T, 97153,… full guide →
Source ↗The founding DMAHS newsletter (Vol. 30 No. 06, April 2020) sets the design: ABA is delivered and prior-authorized through the member's NJ FamilyCare MCO, with the MCO required to "authorize a QHP to assess the child for the development of a proposed treatment plan," and treatment contingent on the MCO's approval of that plan. Fee-for-service — billed to Gainwell Technologies,… full guide →
Source ↗The benefit requires an ASD diagnosis (ICD-10 F84.0–F84.9) made by a qualified healthcare professional — physicians and psychologists (including BCBA-D psychologists) for diagnosis, with BCBAs among the QHPs for treatment planning. Notably, per Optum's NJ Medicaid entry (updated November 2025), a comprehensive diagnostic evaluation is not required to access ABA — a plain ASD… full guide →
Source ↗New Jersey publishes actual FFS rates per 15-minute unit: 97151 assessment at $25.00 (BCBA/BCBA-D), 97153 direct treatment at $15.00 (RBT/BCaBA) — raised from the launch rate of $11.20 effective February 1, 2022 using American Rescue Plan funds after Autism New Jersey's advocacy — 97155 protocol modification at $21.25, and 97156 family training at $25.00. The 97153/97155/97156… full guide →
Source ↗A few rules shape scheduling and billing. Concurrent billing: 97155 is billable while the technician bills 97153 when the QHP is directing the tech face-to-face — but supervision without the tech and patient present is not billable. School settings: the 2020 newsletter said services "may not be provided within a school facility," but Optum's November 2025 NJ entry now permits… full guide →
Source ↗At the technician level, New Jersey layers a Medicaid credential on an unlicensed role. The founding DMAHS newsletter names the RBT as the technician provider — high school diploma or GED, the 40-hour training, a passed competency exam, and "close, ongoing supervision" by a BCBA-D, BCBA, or BCaBA — and its provider-specialty table lists RBT (alongside BCaBA) as the permitted… full guide →
Source ↗The front door is the ABA Authorization Request Form submitted through NaviNet's UM Request Tool, with an ASD diagnosis script from a QHP attached. The assessment step is fast-tracked: once Horizon confirms eligibility, diagnosis, and the script, it issues an assessment authorization of 32 units of 97151 valid for 30 days — no full clinical review at that stage. Treatment is… full guide →
Source ↗Horizon has announced two 2026-era changes we could not fully verify against primary policy text — treat both as "confirm in the portal" items. First, a medical-policy revision effective January 1, 2026 revising criteria for prior authorization and pre-service and post-service medical-necessity reviews (search excerpts reference standardized-instrument testing no more often… full guide →
Source ↗Horizon publishes real ABA escalation contacts: ABA UM escalations go to Erin McNeill (732-256-6336, erin_mcneill@horizonblue.com), the behavioral Medicaid inbox is BHMedicaid_@horizonblue.com, and member services runs at 1-800-682-9091; claims use payor ID 22326. On rates: Horizon publishes no ABA fee schedule — it aligned behavioral-health fees to the DMAHS rate increase for… full guide →
Source ↗Aetna's ABA Program sheet (effective 4/1/2020) publishes rates identical to the state FFS schedule — 97151 $25.00, 97153 $11.20, 97155 $21.25, 97156 $25.00, 0362T $25.00, 0373T $16.40 — and adopts the state's suggested daily unit limits verbatim, explicitly labeling them MUE (medically-unlikely-edit) limits: functionally claim edits, not soft guidance. The catch is the… full guide →
Source ↗ABA sits on the plan's prior-authorization list, with urgent requests decided within 24 hours and routine requests within 7 days. Requests go through Availity or on the plan's behavioral-health prior authorization form; progress reports upload via Availity or fax to (844) 404-3972, and the plan phone is 1-855-232-3596. Claims run through Availity or Office Ally under provider… full guide →
Source ↗No Fidelis-specific ABA clinical policy, fee schedule, or hour-cap document has been published — the plan appears to defer to the state criteria (unverified). Practically, plan requests against the NJ FamilyCare baseline: an ASD diagnosis from a QHP, an MCO-authorized assessment, and treatment contingent on treatment-plan approval, with the state's daily unit guide as the… full guide →
Source ↗The state's BH integration contact sheet — which still titles the plan "Fidelis Care (Formerly Wellcare)" — names the ABA UM/PA contact as Amber Johnson (770-809-7313, Amber.Johnson@centene.com) and the ABA contracting contact as Michael Czajkowski (862-702-6529, Michael.Czajkowski@fideliscarenj.com). Provider services runs at 1-888-453-2534; claims route through Availity… full guide →
Source ↗Optum's NJ Medicaid entry states explicitly that "a comprehensive diagnostic evaluation is not required to access ABA services" — any physician or psychologist ASD diagnosis (F84.0–F84.9) opens the benefit, for members 18 months to 21 years, with coverage keyed to medical necessity and no stated NJ hour caps. It also enumerates the QHP roles and permits services in the school… full guide →
Source ↗ABA and DIR requests submit through Optum's dedicated NJ ABA page on Provider Express (the state's own contact document links abaNJ.html — the direct URL returned a 404 in mid-2026, so navigate from providerexpress.com rather than a saved bookmark); general behavioral-health PA runs by phone at 1-888-362-3368, option 3 for intake, and claims use payer ID 87726. Optum also… full guide →
Source ↗With no published Wellpoint-specific ABA criteria, plan requests against the NJ FamilyCare baseline: ASD diagnosis from a QHP, MCO-authorized assessment, treatment contingent on plan approval, and the state daily unit guide as the likely edit surface. Mechanically, ABA authorization submits through Availity (availity.com) or by phone at (800) 454-3730, with forms at… full guide →
Source ↗ABA network contracting runs through Carelon Behavioral Health (provider.relations.NJ@carelon.com) — a separate funnel from the Wellpoint medical plan, so a practice contracted for medical services isn't automatically in the ABA network. The named ABA clinical contact is Ann Basil, LCSW, Director of BH Services (732-713-7636, ann.basil@wellpoint.com). Provider services runs at… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗P.L. 2009, c.115 (effective February 9, 2010, codified across N.J.S.A. 17:48-6ii and parallel sections for insurers, HMOs, individual and small-employer plans, plus the SHBP and SEHBP) requires state-regulated plans to cover autism screening and diagnosis, medically necessary PT/OT/ST for autism or other developmental disabilities, and medically necessary ABA-based behavioral… full guide →
Source ↗A family saying "we have Aetna" in New Jersey may actually be on the carrier's Medicaid plan — Aetna Better Health of New Jersey, an NJ FamilyCare MCO — which follows the state Medicaid rules (and publishes a rate sheet mirroring the state FFS schedule), not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid… full guide →
Source ↗New Jersey licenses behavior analysts through the State Board of Applied Behavior Analyst Examiners at the Division of Consumer Affairs: the Licensed Applied Behavior Analyst (LBA — master's or doctorate, current BCBA/BCBA-D, and the NJ jurisprudence exam) and the assistant-level LaBA, under N.J.S.A. 45:8B-91 et seq. and N.J.A.C. 13:42B. The board's position is that… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. And unlike Virginia — the one… full guide →
Source ↗P.L. 2009, c.115 (effective February 9, 2010, codified across N.J.S.A. 17:48-6ii and parallel sections for insurers, HMOs, individual and small-employer plans, plus the SHBP and SEHBP) requires state-regulated plans to cover autism screening and diagnosis, medically necessary PT/OT/ST for autism or other developmental disabilities, and medically necessary ABA-based behavioral… full guide →
Source ↗We checked: Cigna / Evernorth publishes no New Jersey-specific ABA policy, form, or supplement, and runs no NJ Medicaid plan — the national EN0499 policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where New Jersey-specific answers come from, not a… full guide →
Source ↗New Jersey licenses behavior analysts through the State Board of Applied Behavior Analyst Examiners at the Division of Consumer Affairs: the Licensed Applied Behavior Analyst (LBA — master's or doctorate, current BCBA/BCBA-D, and the NJ jurisprudence exam) and the assistant-level LaBA, under N.J.S.A. 45:8B-91 et seq. and N.J.A.C. 13:42B. The board's position is that… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. That clinical policy is national — what changes in New Jersey is the legal floor underneath it: the state… full guide →
Source ↗P.L. 2009, c.115 (effective February 9, 2010, codified across N.J.S.A. 17:48-6ii and parallel sections for insurers, HMOs, individual and small-employer plans, plus the SHBP and SEHBP) requires state-regulated plans to cover autism screening and diagnosis, medically necessary PT/OT/ST for autism or other developmental disabilities, and medically necessary ABA-based behavioral… full guide →
Source ↗Optum's ABA State Mandates document (BH803ABASTM12026, effective January 2026) does carry a dedicated New Jersey section — but it's "For New Jersey Medicaid members" only, governing the carrier's NJ FamilyCare plan (no comprehensive diagnostic evaluation required, ages 18 months to 21, school setting outside school hours). There is no New Jersey commercial-specific entry, so… full guide →
Source ↗A family saying "we have UnitedHealthcare" in New Jersey may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan, an NJ FamilyCare MCO with behavioral health administered by Optum — which follows the state Medicaid rules and Optum's NJ Medicaid entry, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated… full guide →
Source ↗New Jersey licenses behavior analysts through the State Board of Applied Behavior Analyst Examiners at the Division of Consumer Affairs: the Licensed Applied Behavior Analyst (LBA — master's or doctorate, current BCBA/BCBA-D, and the NJ jurisprudence exam) and the assistant-level LaBA, under N.J.S.A. 45:8B-91 et seq. and N.J.A.C. 13:42B. The board's position is that… full guide →
Source ↗The MDH ABA Provider Manual states it directly: ABA services are covered and reimbursed by the Medical Assistance fee-for-service program through its BHASO, Carelon Behavioral Health. MDH's HealthChoice pages say the same thing from the other side — specialty behavioral health is carved out of managed care, and the state pays providers directly. The practical consequences for… full guide →
Source ↗All ABA services require prior authorization from the BHASO — the assessment included. The gate before everything is the Comprehensive Diagnostic Evaluation (CDE): a QHCP (developmental pediatrician, pediatrician, pediatric neurologist, child psychiatrist, clinical psychologist, neuropsychologist, or nurse practitioner) must complete a CDE with direct observation, caregiver… full guide →
Source ↗The manual effective February 1, 2026 carries the current statewide fee schedule, tiered by credential per 15-minute unit: 97151 assessment pays $38.34 (psychologist/BCBA-D/BCBA, daily max 32 units); 97153 direct treatment pays $24.41 at the BCBA tier, $20.91 BCaBA, and $19.17 RBT/BT (daily max 32 units); 97155 protocol modification pays $38.34 (daily max 24 units, GT modifier… full guide →
Source ↗Only ABA groups, psychologists, BCBA-Ds, and BCBAs can bill directly — BCaBAs, RBTs, and BTs render under them. Maryland has an unusual workforce on-ramp: Behavior Technicians can enroll in Medicaid before earning RBT certification (specialty code 325), with a 90-day grace period to submit RBT proof. Licensed psychologists may render and bill ABA with an attestation (40… full guide →
Source ↗Maryland's defining staffing rule: every individual who renders ABA — psychologist, BCBA-D, BCBA, BCaBA, RBT, and even not-yet-certified BTs — enrolls with Maryland Medicaid individually through ePREP, on top of the group's own enrollment. The technician floor is codified in state regulation, not just BACB policy: under COMAR 10.09.28.02, an RBT must be 18 or older, hold… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Maryland has no standalone "autism mandate" — ABA is covered as a habilitative service for children with ASD under Insurance § 15-835, with the ABA-specific rules in COMAR 31.10.39.03 (effective April 3, 2014). The statute requires Maryland-regulated insurers, nonprofit health service plans, and HMOs to cover habilitative services until at least the end of the month the… full guide →
Source ↗A family saying "we have Aetna" in Maryland may be on Aetna Better Health of Maryland, a HealthChoice MCO — but unlike other states, that changes nothing for ABA. Maryland carves ABA (and all specialty behavioral health) out of the MCOs entirely: authorizations and claims go to Carelon Behavioral Health, the state's BHASO, under the Medicaid fee-for-service rules. If the card… full guide →
Source ↗Maryland has required licensure to practice behavior analysis since January 2015: the Licensed Behavior Analyst (LBA) credential, administered by the Behavior Analyst Advisory Committee of the State Board of Professional Counselors and Therapists (Health Occupations Title 17, Subtitle 6A; COMAR 10.58.16), built on current BACB certification, a qualifying master's degree, and a… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Maryland has no standalone "autism mandate" — ABA is covered as a habilitative service for children with ASD under Insurance § 15-835, with the ABA-specific rules in COMAR 31.10.39.03 (effective April 3, 2014). The statute requires Maryland-regulated insurers, nonprofit health service plans, and HMOs to cover habilitative services until at least the end of the month the… full guide →
Source ↗We checked the current EN0499 (effective May 15, 2026) in full: it contains no Maryland entry, carve-out, or state-specific exhibit — only the generic clause that a controlling federal or state coverage mandate supersedes the policy. So for fully-insured Cigna members in Maryland, the § 15-835 / COMAR 31.10.39 protections layer directly on top of the national policy without… full guide →
Source ↗Maryland has required licensure to practice behavior analysis since January 2015: the Licensed Behavior Analyst (LBA) credential, administered by the Behavior Analyst Advisory Committee of the State Board of Professional Counselors and Therapists (Health Occupations Title 17, Subtitle 6A; COMAR 10.58.16), built on current BACB certification, a qualifying master's degree, and a… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. That clinical policy is national — what changes in Maryland is the legal floor underneath it: the state mandate… full guide →
Source ↗Maryland has its own entry in Optum's ABA State Mandates supplemental criteria (BH803ABA): for fully-insured policies in Maryland, Optum directs reviewers to use the COMAR 31.10.39.03 criteria (April 3, 2014) in place of its standard medical-necessity rules. The document reproduces the Maryland requirements — comprehensive evaluation, physician prescription with treatment… full guide →
Source ↗The legal base: Maryland has no standalone autism mandate — ABA rides on the habilitative-services mandate, Insurance § 15-835, which requires Maryland-regulated insurers, nonprofit health service plans, and HMOs to cover habilitative services until at least the end of the month the enrollee turns 19, with the ABA-specific medical-necessity rules delegated to the Insurance… full guide →
Source ↗A family saying "we have UnitedHealthcare" in Maryland may be on UnitedHealthcare Community Plan, a HealthChoice MCO — but that changes nothing for ABA. Maryland carves ABA out of the MCOs entirely: authorizations and claims go to Carelon Behavioral Health, the state's BHASO, under the Medicaid fee-for-service rules — use our Maryland Medicaid guide. One historical wrinkle… full guide →
Source ↗Maryland has required licensure to practice behavior analysis since January 2015: the Licensed Behavior Analyst (LBA) credential, administered by the Behavior Analyst Advisory Committee of the State Board of Professional Counselors and Therapists (Health Occupations Title 17, Subtitle 6A; COMAR 10.58.16), built on current BACB certification, a qualifying master's degree, and a… full guide →
Source ↗Under ACC Phase III (launched July 1, 2025), Colorado runs four Regional Accountable Entities — RMHP (Region 1), Northeast Health Partners (Region 2), Colorado Community Health Alliance (Region 3), and Colorado Access (Region 4) — that administer the capitated behavioral health benefit, plus the Elevate (Denver Health) physical-health MCO. PBT/ABA sits outside all of it: it is… full guide →
Source ↗Colorado's Criteria for Behavioral Therapies (February 2023) require only ONE of three things: (1) a diagnosed condition for which behavioral therapy is evidence-based or evidence-informed — "including" ASD, but explicitly not limited to it; (2) an inability to adequately participate in home, school, or community activities because of a behavior or skill deficit, supported by… full guide →
Source ↗The PBT Billing Manual is blunt: "All PBT services must be pre-approved in a Prior Authorization Request (PAR) process" — including the 97151 assessment, which many states leave auth-free. PARs go to Acentra through the Atrezzo portal (ColoradoPAR.com) and must include the ordering practitioner's prescription or Plan of Care with a diagnosis (ICD-10 preferred), a standardized… full guide →
Source ↗Colorado's fee schedule has three quirks intake and billing must both know. First, 97151 pays a FLAT amount per assessment — $882.78 on the July 2025 schedule, billable once per 365 days — rather than per 15-minute unit (97151-TJ pays $40.24/unit, set at 2 units per 365 days). Second, 97156 does not exist here: the family adaptive behavior treatment guidance code is absent… full guide →
Source ↗Colorado turned technician credentialing into a billing condition in late 2025. Emergency rule MSB 25-09-04-A created Section 8.281 (emergency effective October 10, 2025; finally adopted December 12, 2025) after federal audit findings that uncredentialed technicians had been reimbursed — preliminary estimates put the potential repayment to CMS as high as $59 million. The rule… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Colorado's mandate — C.R.S. § 10-16-104(1.4), originally 2009's SB 09-244 — is one of the stronger ones in our directory: it applies to all health benefit plans issued or renewed in Colorado except short-term limited-duration policies and individual grandfathered plans, carries no age limits, and carries no dollar caps — the historical $34,000/year (birth-8) and $12,000/year… full guide →
Source ↗We checked: Aetna publishes no Colorado-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Colorado-specific answers come from, not a carrier document.
Source ↗Colorado currently requires no state license to practice behavior analysis — BCBA/BACB certification is the operative credential. That is changing: HB26-1425 (signed June 2, 2026) creates a Colorado Behavior Analyst Licensing Board under DORA's Division of Professions and Occupations, and on and after July 1, 2028 practicing ABA without a behavior analyst or assistant behavior… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Colorado's mandate — C.R.S. § 10-16-104(1.4), originally 2009's SB 09-244 — is one of the stronger ones in our directory: it applies to all health benefit plans issued or renewed in Colorado except short-term limited-duration policies and individual grandfathered plans, carries no age limits, and carries no dollar caps — the historical $34,000/year (birth-8) and $12,000/year… full guide →
Source ↗Unlike Virginia — where EN0499 explicitly does not apply to fully-insured business — we found no Colorado carve-out in the policy, so the national rules (including the no-assessment-PA fast path) should apply to Colorado members. One honesty note: the current EN0499 PDF could not be fully text-parsed to confirm the state-exceptions list with certainty, so treat "no Colorado… full guide →
Source ↗Colorado currently requires no state license to practice behavior analysis — BCBA/BACB certification is the operative credential. That is changing: HB26-1425 (signed June 2, 2026) creates a Colorado Behavior Analyst Licensing Board under DORA's Division of Professions and Occupations, and on and after July 1, 2028 practicing ABA without a behavior analyst or assistant behavior… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Colorado's mandate — C.R.S. § 10-16-104(1.4), originally 2009's SB 09-244 — is one of the stronger ones in our directory: it applies to all health benefit plans issued or renewed in Colorado except short-term limited-duration policies and individual grandfathered plans, carries no age limits, and carries no dollar caps — the historical $34,000/year (birth-8) and $12,000/year… full guide →
Source ↗UnitedHealthcare's Medicaid footprint in Colorado runs through Rocky Mountain Health Plans (a UnitedHealthcare company) — RAE Region 1, the RMHP PRIME product, and RMHP CHP+. But unlike most states, that does not create a separate UHC Medicaid ABA process: ABA is a statewide fee-for-service carve-out from the RAE capitation, so RMHP does not authorize or pay ABA claims. A… full guide →
Source ↗Colorado currently requires no state license to practice behavior analysis — BCBA/BACB certification is the operative credential. That is changing: HB26-1425 (signed June 2, 2026) creates a Colorado Behavior Analyst Licensing Board under DORA's Division of Professions and Occupations, and on and after July 1, 2028 practicing ABA without a behavior analyst or assistant behavior… full guide →
Source ↗Anthem's Colorado precertification list carries an explicit "Responsible party" column, and it spells out how to read it: if Anthem is listed, Anthem reviews; if Carelon Medical Benefits Management is listed, Carelon reviews; if CarelonRx is listed, CarelonRx reviews. The behavioral health row reads "Behavioral Health Services — Inpatient and Outpatient," responsible party… full guide →
Source ↗Plenty of ABA billing playbooks still say Anthem reviews ABA under clinical guideline CG-BEH-02, "Adaptive Behavioral Treatment." For Colorado commercial that stopped being true in 2024. A signed Anthem letter to Colorado providers, dated February 1, 2024 and flagged as a material adverse change, states that beginning with dates of service on or after June 1, 2024, Anthem and… full guide →
Source ↗Effective March 1, 2026, Anthem reimburses ABA in Colorado based on weekly approved units rather than total authorized units. Anthem's own framing of the consequence is blunt: claims should reflect the units rendered within each week, up to the weekly medically necessary limit as approved by prior approval, and claims submitted with units exceeding the weekly limit will be… full guide →
Source ↗Colorado's mandate — C.R.S. § 10-16-104(1.4), added by SB 09-244 — requires all health benefit plans issued or renewed in the state to cover the assessment, diagnosis and treatment of autism spectrum disorders, and it names applied behavior analysis explicitly in the definition of covered treatment. It is one of the stronger mandates in this directory for three reasons. First,… full guide →
Source ↗A physician or psychologist must order it The statute says treatment for autism spectrum disorders shall be prescribed or ordered by a licensed physician or licensed psychologist. A BCBA's recommendation alone does not satisfy it — capture the ordering clinician at intake, not at appeal. The treatment plan is tied to the medical home Colorado requires the treatment plan to be… full guide →
Source ↗Colorado has historically not licensed behavior analysts, leaning instead on the statutory "autism services provider" ladder and BACB certification. That changed in 2026: HB26-1425 became law and creates the Colorado Behavior Analyst Licensing Board under the Division of Professions and Occupations at DORA, with authority to license behavior analysts and assistant behavior… full guide →
Source ↗AMPM 320-S applies across every AHCCCS delivery system — ACC, ALTCS, DES/DDD, DCS/CMDP, the RBHA contracts, and fee-for-service tribal programs — but the operational path splits in two. Most children get ABA through their ACC plan: Arizona Complete Health-Complete Care Plan, Banner-University Family Care, Blue Cross Blue Shield of Arizona Health Choice, Mercy Care, Molina… full guide →
Source ↗AMPM 320-S states that Behavior Analysis Services are a covered benefit "for individuals with Autism Spectrum Disorder (ASD) and/or other diagnoses as justified by medical necessity" — Arizona is one of the states that does not strictly require an autism diagnosis for ABA. Services must be prescribed or recommended by a qualified Behavioral Health Professional based on… full guide →
Source ↗AHCCCS converted the ABA codes from by-report to fixed rates effective November 1, 2023, tiered by rendering credential via modifiers: HM = below bachelor's (BT/RBT level), HN = bachelor's (BCaBA), HO = master's (BCBA), HP = doctoral (BCBA-D). Per 15-minute unit: 97151 assessment pays $30.06 / $35.78 / $44.73 at the HN/HO/HP tiers; 97153 direct treatment pays $17.91 / $21.32 /… full guide →
Source ↗Arizona ABA is mid-upheaval, and intake teams should track two live threads. First, AHCCCS is running a spending-driven ABA reform: proposed AMPM 320-S revisions previewed at April 15–16, 2026 webinars would make state licensure plus fingerprint clearance conditions of AHCCCS provider registration and change the PA process. As of this review (8/1/2026), the proposal has moved… full guide →
Source ↗AMPM 320-S never says "RBT." A Behavior Technician is "a paraprofessional credentialed by a nationally recognized Behavior Analyst certification board or as specified in A.A.C. R9-10-101(39)" — meaning either a nationally certified tech (the RBT pathway) or an unlicensed Behavioral Health Technician working at a licensed health care institution under Behavioral Health… full guide →
Source ↗Assessments start without authorization — the plan's ABA page says directly that you don't need PA for adaptive behavior assessment codes 97151 and 97152 — so eligibility verification can flow straight into a booked assessment. Treatment codes 97153–97158 require PA, and payment may be denied for services delivered without it. Requests go on Mercy Care's dedicated ABA PA form… full guide →
Source ↗A Mercy Care contract touches three distinct member populations: ACC members, DDD/ALTCS members via Mercy Care DD, and foster-care children via the DCS Comprehensive Health Plan — one credentialing relationship, three intake funnels. Two billing quirks matter at intake. First, coordination of benefits: the 9715x CPT codes require billing primary insurance first when the member… full guide →
Source ↗Assessments (97151/97152) start without authorization; every other ABA code requires PA, submitted through the online ABA Treatment Form on Provider Express or by fax to 1-888-541-6691. The treatment request is where Optum's rigor lives — it must include baseline and mastery criteria, a transition plan, discharge criteria, a behavior-reduction/crisis plan, parent goals, and… full guide →
Source ↗The orientation is explicit that UHC Community Plan is "the selected managed care administrator for Arizona AHCCCS Complete Care and AZ DD membership" — DD member cards say "DDD Health Plan by UHCCP" and carry Group AZDDD, versus AZHCCCS for ACC members. Same forms and rules, but confirm which book the member is in, since the DDD path comes with a different eligibility gate… full guide →
Source ↗Initiation under CP.BH.104 requires medical stability, a behavioral assessment completed by a BCBA (or state-law equivalent) using record review, interviews, rating scales, and direct observation, plus an FBA — descriptive, traditional, or IISCA — or a skills assessment from a named list (VB-MAPP, ABLLS-R, AFLS, PEAK, SSIS, EFL, Socially Savvy), feeding an individualized… full guide →
Source ↗CP.BH.104 asks for a confirmed ASD diagnosis (current DSM, confirmed via tools like the ADOS-2, ADI-R, or CARS-2) "or an appropriate diagnosis as otherwise specified according to state-defined ABA criteria" — and that escape clause is what reconciles the corporate policy with Arizona's no-ASD-required Medicaid rule. When the diagnosis is non-ASD, cite AMPM 320-S explicitly in… full guide →
Source ↗Banner lists an "Applied Behavior Analysis (ABA) Prior Authorization Form" among its behavioral-health materials, which confirms treatment PA exists — but the plan publishes no ABA clinical policy, no assessment-PA rule, no authorization durations, and no hour guidance that we could verify. The honest operating assumption is the state baseline: AMPM 320-S clinical criteria… full guide →
Source ↗Banner-University Family Care operates as an ACC plan in Maricopa, Pinal, Cochise, Gila, Graham, Greenlee, La Paz, Pima, Santa Cruz, and Yuma counties, plus ALTCS in ten counties — the second-largest geographic reach after Arizona Complete Health. For intake, that means Banner cards show up across both metro Phoenix and southern Arizona; treat every one as an AMPM 320-S case… full guide →
Source ↗Health Choice runs prior authorization from PA Guidelines grids rather than a published ABA program document, and the grids revise often — at least seven versions between January 2024 and May 2026. We could not verify the current grid rows for 97151 or 97153–97158, so the intake rule for this plan is procedural: pull the newest grid from healthchoiceaz.com (or ask via the PA… full guide →
Source ↗Health Choice's ACC footprint centers on the five northern counties — Apache, Coconino, Mohave, Navajo, Yavapai — where, after Care1st folded into Arizona Complete Health, the practical plan choice is Health Choice vs. AzCH, plus its Maricopa/Gila/Pinal presence. Providers building northern-Arizona intake should have both plans' machinery mapped, because families in those… full guide →
Source ↗Nothing we could verify shows Molina layering clinical criteria beyond AMPM 320-S — so the coverage conversation follows the state guide: no strict autism-diagnosis requirement, BHP-recommended services based on assessment, 6-month progress reports. The mechanics run through Molina's Prior Auth and Pre-Service Review Guide, with PA initiated via Healthcare Services at (844)… full guide →
Source ↗Children under 21 can get ABA either through their ACC plan under EPSDT or — if ALTCS/DDD-eligible — through a DDD Health Plan. Autism is a DDD qualifying-condition category, and over age 3 ALTCS approval is the gate to DDD-funded services (habilitation, respite, ABA). Once eligible, the family chooses between Mercy Care DD and UHCCP DD, and unlike the ACC side, both DDD… full guide →
Source ↗A DDD family isn't just an ABA inquiry — DDD members also receive habilitation and respite through home- and community-based services alongside ABA, a bundled-service conversation ACC-only families never have. Intake that recognizes a DDD card (UHCCP DD cards read "DDD Health Plan by UHCCP," Group AZDDD; Mercy Care DD is branded accordingly) can coordinate the ABA request with… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Steven's Law (HB 2847, 2008) lives in four parallel sections of the insurance code — A.R.S. §§ 20-826.04, 20-1057.11, 20-1402.03, and 20-1404.03 — covering state-regulated group coverage: large-group contracts, HMO plans, and group and blanket disability policies. Plans may not deny or limit treatment based solely on an autism spectrum disorder diagnosis, and may not exclude… full guide →
Source ↗A family saying "we have Aetna" in Arizona may actually be a Mercy Care member — Mercy Care is administered by Aetna Medicaid Administrators LLC and covers the largest Phoenix-metro Medicaid, DDD, and foster-care books. Mercy Care runs on AHCCCS rules (AMPM 320-S), not this commercial policy: no autism diagnosis required, no PA on assessment codes. Verify which line of… full guide →
Source ↗Arizona requires a state license to practice behavior analysis — A.R.S. § 32-2091, administered by the Arizona Board of Psychologist Examiners (behavior analysts sit under the psychology board, not a standalone board) — and BCBA certification alone is not sufficient; AHCCCS itself defines "Behavior Analyst" as a person licensed under § 32-2091. On rates: Aetna does not publish… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form — EN0499 expects a confirmed… full guide →
Source ↗Steven's Law (HB 2847, 2008) lives in four parallel sections of the insurance code — A.R.S. §§ 20-826.04, 20-1057.11, 20-1402.03, and 20-1404.03 — covering state-regulated group coverage: large-group contracts, HMO plans, and group and blanket disability policies. Plans may not deny or limit treatment based solely on an autism spectrum disorder diagnosis, and may not exclude… full guide →
Source ↗We checked: the current EN0499's state-mandate paragraph names only New York and Virginia — there is no Arizona carve-out, so Arizona fully-insured business runs on the standard EN0499 criteria, including the no-assessment-PA fast path and the 60-day assessment-instrument recency rule. Cigna publishes no Arizona-specific ABA policy or supplement, and it runs no AHCCCS Medicaid… full guide →
Source ↗Arizona requires a state license to practice behavior analysis — A.R.S. § 32-2091, administered by the Arizona Board of Psychologist Examiners (behavior analysts sit under the psychology board, not a standalone board) — and BCBA certification alone is not sufficient; AHCCCS itself defines "Behavior Analyst" as a person licensed under § 32-2091. On rates: Cigna does not publish… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. That clinical policy is national — what changes in Arizona is the legal floor underneath it: the state mandate… full guide →
Source ↗Steven's Law (HB 2847, 2008) lives in four parallel sections of the insurance code — A.R.S. §§ 20-826.04, 20-1057.11, 20-1402.03, and 20-1404.03 — covering state-regulated group coverage: large-group contracts, HMO plans, and group and blanket disability policies. Plans may not deny or limit treatment based solely on an autism spectrum disorder diagnosis, and may not exclude… full guide →
Source ↗Arizona has its own entry in Optum's ABA State Mandates supplemental criteria (BH803ABASTM12026, effective January 2026): for Arizona commercial plans, Optum operationalizes SB 1590 — the repeal of the maximum benefit limits for members 16 and under and the DSM-based ASD definition. In practice that means Optum's own criteria document already reflects the cap repeal, so a UM… full guide →
Source ↗A family saying "we have UnitedHealthcare" in Arizona may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of Arizona, which is both an ACC plan and one of the two statewide DDD Health Plans ("DD by UHCCP"), with ABA administered by Optum under AHCCCS rules: no autism diagnosis required, no PA on 97151/97152, its own AZ treatment-request forms.… full guide →
Source ↗Arizona requires a state license to practice behavior analysis — A.R.S. § 32-2091, administered by the Arizona Board of Psychologist Examiners (behavior analysts sit under the psychology board, not a standalone board) — and BCBA certification alone is not sufficient; AHCCCS itself defines "Behavior Analyst" as a person licensed under § 32-2091. On rates: UnitedHealthcare does… full guide →
Source ↗Nothing in the current FFS ABA Policy Manual (updated October 1, 2025) requires prior authorization or prior approval — for the assessment or for treatment. The gate is a referral from a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant (LBAs cannot diagnose or self-refer). The… full guide →
Source ↗Effective January 1, 2023, ABA was carved into the mainstream Medicaid Managed Care benefit package — and since most children are enrolled in MMC, most New York ABA runs through a plan, not through eMedNY. The state's own manual is blunt about what that means: providers serving an MMC member "must contact the MMC member's specific MMC plan for coverage, billing, and… full guide →
Source ↗The FFS fee schedule is flat: one statewide rate per code, no credential tiers, no modifiers, no geographic variation. Assessment (97151) and the QHP codes (97155 protocol modification, 97156 family guidance) pay $19.26 per 15-minute unit; group codes 97154/97157/97158 pay $3.31 per unit per member. The story is 97153, technician-delivered direct treatment — the volume code of… full guide →
Source ↗New York is one of the strictest licensure states in the country: only NYSED Licensed Behavior Analysts (LBAs) can enroll in Medicaid and bill — a BCBA credential alone is not sufficient. Certified Behavior Analyst Assistants (CBAAs) enroll as non-billing (OPRA) providers and bill through their supervising LBA, and unlicensed technicians may deliver scripted 97153 sessions… full guide →
Source ↗New York has no RBT mandate. The FFS manual defines the technician tier simply as an "unlicensed individual" — someone not licensed, certified, or registered by the state as an ABA provider — with no credential, training-hour, age, or education requirement attached. What the state regulates instead is scope: an LBA may not delegate any task within the ABA scope of practice,… full guide →
Source ↗A behavioral assessment by a BCBA/LBA-equivalent must be completed before treatment is requested, and the treatment request must show results from at least one specified functional behavior assessment (descriptive FBA, traditional FA, or IISCA) and/or a named skill assessment — VB-MAPP, ABLLS-R, AFLS, PEAK, SSIS, EFL, or Socially Savvy; a Vineland alone is explicitly… full guide →
Source ↗Fidelis runs two clocks: the diagnostic evaluation supporting the request must be within 2 years of the authorization request, and initial requests need a DSM-5 diagnosis made with a validated assessment tool administered within the past 60 months (not required for continuing services). That instrument requirement is stricter than the state's referral rule; the 60-month window… full guide →
Source ↗No ABA in school settings since September 1, 2023 — and for treatment during school hours, providers must first contact the local Committee on Special Education for an independent evaluation, so a school-hours request is a coordination project, not a form field. Every ABA practitioner must complete both Fidelis credentialing and MMIS Medicaid enrollment before serving members,… full guide →
Source ↗Where the state FFS layer needs only a referral, UHC's plan requires prior authorization for every ABA service. The assessment PA goes in as an online ABA Assessment request on providerexpress.com; the treatment PA follows through the portal or by calling the Autism Care Advocate with the member's name and ID, diagnosis, and a description of the treatment plan, and… full guide →
Source ↗Optum's ABA State Mandates supplemental criteria (BH 803ABA, effective January 2026) carries an explicit "New York Medicaid and Child Health Plus (CHP)" entry that restates the state criteria: under 21, ASD and/or Rett syndrome, and the 2-year practitioner referral including the DSM-5 Diagnostic Checklist. So the referral packet you'd assemble for FFS is the same clinical… full guide →
Source ↗Treatment authorization runs on Anthem's Treatment Plan Request Form for Autism Spectrum Disorders — New York Medicaid (form NY-BCBS-CD-008303-26-GRP2461, June 2026 revision), submitted via Availity.com as the preferred channel. The form requires the treating BCBA/QHCP's information, captures the member's age at first ABA treatment, and classifies the request as Comprehensive… full guide →
Source ↗Several operational facts have no published answer we could verify: whether the assessment code 97151 itself requires PA (the plan's published process is a treatment-plan-request workflow), whether Carelon Behavioral Health plays a UM role for ABA, and any hour caps or rates. Anthem also maintains an ABA Services FAQ for NY providers (provider news article 13424) that wasn't… full guide →
Source ↗Verified: Healthfirst publishes its own ABA authorization policy (the prior version circulated as doc 0374-22, with an updated version announced carrying a reported October 2026 effective date), routes prior authorization through the Availity Essentials Online Authorization Tool with "Healthfirst (New York)" selected as the payer, and — on its commercial small/large group… full guide →
Source ↗Healthfirst's published ABA content mirrors the state program: members under 21 with ASD and/or Rett syndrome, the practitioner referral, and — per its supervision post — the state's LBA/CBAA structure with the 5%-of-tech-hours, two-contacts-per-month supervision rule. So the intake package is the same one the state FFS manual defines; the open question at this plan is purely… full guide →
Source ↗MetroPlus states that LBAs do not meet the practitioner level to authenticate or validate an autism diagnosis — so ABA providers must coordinate with the member's treatment team (physician, psychologist, or other qualified NYS-licensed clinician) to have the diagnosis authenticated and validated annually. That's a materially tighter clock than the state's 2-year referral: for… full guide →
Source ↗Per the plan's 2023 benefit notice, authorization requests and supporting clinical information are submitted to MetroPlus CSS by email or fax — build a submission template and a delivery-confirmation habit, since email/fax workflows lack a portal's status visibility. Assessment-PA specifics, authorization periods, hour caps, and rates aren't published in the materials we could… full guide →
Source ↗EmblemHealth's published ABA benefit page restates the state program: members under 21 with ASD and/or Rett syndrome per DSM-5, referred by the state's practitioner list, effective with the 2023 carve-in. No named assessment instruments, no plan-specific recency rules, no published intensity framework — the clinical criteria are the state's. What the public materials don't… full guide →
Source ↗Until September 1, 2021, Molina NY's ABA authorizations ran through eviCore; since then, assessments and treatment plans are reviewed in-house by Molina's ABA care-review clinicians, including LBA reviewers, with PA code changes effective October 1, 2021. That transition is the plan's defining operational fact: eviCore-era submission instructions, fax numbers, and code lists… full guide →
Source ↗Molina's current published materials don't answer the operational questions intake needs: whether 97151 requires PA separately from treatment, authorization periods, documentation requirements, hour-cap logic, or rates — and its clinical criteria versus the state baseline are unverified. Until the plan confirms otherwise, work from the state's clinical baseline (under 21,… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗New York's autism mandate — enacted via S.5845 (2011), effective for policies issued or renewed on or after November 1, 2012, and implemented through DFS Insurance Circular Letter No. 6 (2014) — requires every state-regulated policy providing physician/medical coverage (individual, group, Article 43/HMO, student plans, municipal cooperatives) to cover screening, diagnosis, and… full guide →
Source ↗We checked: Aetna publishes no New York-specific ABA policy, form, or supplement — the national CPBs, national precert forms, and the state mandate are the whole picture, with the no-ABA-only-limits rule and the LBA credential gate reaching Aetna's fully-insured NY plans through the Insurance Law rather than any Aetna document. One adjacent trap: Aetna Better Health appears in… full guide →
Source ↗New York is one of the strictest licensure states: practicing ABA requires the NYSED Licensed Behavior Analyst (LBA) credential under Education Law Article 167 (§§ 8800–8808; regulations at 8 NYCRR 79-17/79-18), administered by NYSED's Office of the Professions — a BCBA alone cannot practice or bill, and the mandate itself conditions commercial ABA coverage on LBA/CBAA… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. Unlike Virginia, New York gets… full guide →
Source ↗New York's autism mandate — enacted via S.5845 (2011), effective for policies issued or renewed on or after November 1, 2012, and implemented through DFS Insurance Circular Letter No. 6 (2014) — requires every state-regulated policy providing physician/medical coverage (individual, group, Article 43/HMO, student plans, municipal cooperatives) to cover screening, diagnosis, and… full guide →
Source ↗New York is one of the strictest licensure states: practicing ABA requires the NYSED Licensed Behavior Analyst (LBA) credential under Education Law Article 167 (§§ 8800–8808; regulations at 8 NYCRR 79-17/79-18), administered by NYSED's Office of the Professions — a BCBA alone cannot practice or bill, and the mandate itself conditions commercial ABA coverage on LBA/CBAA… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. That clinical policy is national — what changes in New York is the legal floor underneath it: the state mandate… full guide →
Source ↗New York's autism mandate — enacted via S.5845 (2011), effective for policies issued or renewed on or after November 1, 2012, and implemented through DFS Insurance Circular Letter No. 6 (2014) — requires every state-regulated policy providing physician/medical coverage (individual, group, Article 43/HMO, student plans, municipal cooperatives) to cover screening, diagnosis, and… full guide →
Source ↗A family saying "we have UnitedHealthcare" in New York may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of New York, where ABA is managed by Optum under the state Medicaid rules with all services PA-gated through Provider Express. Same portal, different rulebook: verify which line of business the card belongs to, and use the dedicated guide for… full guide →
Source ↗New York is one of the strictest licensure states: practicing ABA requires the NYSED Licensed Behavior Analyst (LBA) credential under Education Law Article 167 (§§ 8800–8808; regulations at 8 NYCRR 79-17/79-18), administered by NYSED's Office of the Professions — a BCBA alone cannot practice or bill, and the mandate itself conditions commercial ABA coverage on LBA/CBAA… full guide →
Source ↗Excellus publishes its own dedicated ABA clinical policy — Medical Policy 3.01.11, "Applied Behavior Analysis" (current version effective June 18, 2026) — rather than leaving coverage entirely to the state baseline. The policy deems ABA medically appropriate for DSM-5-TR autism spectrum disorder, treats alternative approaches (DIR/Floortime, TEACCH, RDI) as investigational,… full guide →
Source ↗Beyond the state's referral packet, Excellus's medical policy calls for a specific documentation set at review: psychological/other testing reports, a copy of the IEP where one exists, Early Intervention or Preschool progress notes, the frequency/duration/location of requested sessions, the treating provider's certification/credentials, requested supervision hours, and an… full guide →
Source ↗We found no Excellus-published list stating whether the assessment (97151) or the treatment codes require prior authorization for outpatient ABA specifically — the medical policy describes a "medical necessity review... when applicable" rather than a hard PA gate tied to each code. Excellus's general prior-authorization guidance for Medicaid Managed Care and HARP members… full guide →
Source ↗Excellus's general Telemedicine and Telehealth medical policy — its most recent confirmed revision markers run only through 2017 — does not list any ABA codes (97151–97158) in its covered CPT/HCPCS table, and the ABA medical policy itself only cites third-party guidance (the Council of Autism Service Providers' 2021 telehealth practice parameter) as supportive literature, not… full guide →
Source ↗MVP publishes a standalone "Applied Behavior Analysis Services" payment policy (current version effective 4/1/2026), reviewed most recently February 2026 with no changes. It lists the covered codes — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, and 0373T — but carries a Medicaid-specific carve-out worth flagging for billing: "The following procedures are… full guide →
Source ↗MVP's Behavioral Health Services and Authorization Requirements grid states plainly that Applied Behavior Analysis for NY Medicaid (including CHP) carries "Auth Required," effective with the Medicaid ABA benefit's own 1/1/2023 start date, for children ages 0–20. The ABA payment policy confirms prior authorization is required "for ABA Assessments and Services" alike, and its… full guide →
Source ↗Effective July 1, 2025, MVP will not reimburse any ABA code (97151–97158, 0362T, 0373T) billed with Place of Service = School — a FastFax notice confirms requests for school-setting delivery are "administratively denied," and treatment plans submitted with a PA request must now specify the place(s) of service. ABA also isn't covered as a substitute for Early Intervention or… full guide →
Source ↗MVP's ABA payment policy ties telehealth reimbursement to a federal waiver rather than stating a firm standing rule: "MVP shall reimburse ABA services delivered via video-enabled telehealth through March 31, 2025, or until the CMS waiver expires, whichever is later. Following the expiration or change of the waiver, MVP may deny ABA services delivered via telehealth in… full guide →
Source ↗CDPHP's Provider Office Administrative Manual, Section 18 (Behavioral Health), names the ABA benefit directly: "Applied behavior analysis — Coverage is not subject to a maximum benefit and the individual is covered until the services are no longer medically necessary." It lists the CPT codes in scope — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 — and requires that… full guide →
Source ↗CDPHP's general behavioral-health rule is that no authorization is required for outpatient mental health or substance-use-disorder treatment by participating psychiatrists, psychiatric NPs, psychologists, LMSWs, and mental health counselors — but "certain behavioral health services in Medicaid–Select Plan and Medicaid–HARP require prior authorization by calling the Behavioral… full guide →
Source ↗CDPHP has no published ABA-specific telehealth billing policy (place-of-service code, modifier, or reimbursement parity) in any document we could access; its behavioral-health provider resources instead link out to the American Telemedicine Association's 2017 "Practice Guidelines for Telemental Health with Children and Adolescents" — a third-party clinical-practice standard,… full guide →
Source ↗Independent Health states directly, on its current provider policies page, that "Carelon now oversees all behavioral health benefit management services for our MediSource, MediSource Connect, Child Health Plus and Essential Plans" — covering appeals, care management, claims, eligibility, prior authorization, network operations, and utilization review for behavioral health… full guide →
Source ↗The MediSource handbook states ABA is covered for children/youth under 21 with autism spectrum disorder and/or Rett syndrome, with assessment and treatment delivered by a physician, Licensed Behavior Analyst (LBA), or Certified Behavior Analyst Assistant (CBAA) working under LBA supervision — matching the state's licensure framework. Covered service types named include… full guide →
Source ↗No Independent Health document we could access confirms whether the ABA assessment or treatment codes require prior authorization for MediSource — the handbook's general member-facing PA-required list (out-of-plan services, subacute/SNF admissions, home care, personal care, PERS, mental health, DME, certain surgeries) does not name ABA specifically, but that list is a… full guide →
Source ↗Highmark WNY's Medicaid/CHPlus Provider Manual states its Autism Spectrum Disorder section plainly: "The maximum applied behavioral health analysis benefit is $45,000 per calendar year" — a specific dollar figure this guide has not found published this precisely by any other upstate NY Medicaid plan. The manual's Behavioral Health prior-authorization table confirms ABA… full guide →
Source ↗Highmark WNY publishes a standalone "Request for Authorization: Autism Spectrum Disorder Testing" form (Feb 2026) covering the psych/neuropsych testing codes used to diagnose ASD (96130, 96131, 96136–96139), requiring clinical history, validated screener results (ASRS, SCQ, SRS, M-CHAT, CARS, GARS, GADS), and DSM-5/ICD-10 codes — and it explicitly asks "Is this a request to… full guide →
Source ↗A Highmark WNY provider bulletin (originally issued June 2020 for COVID-19, republished January 2022) names the exact ABA telehealth codes it recognizes: "Highmark BCBSWNY would recognize ABA therapy for functional behavior assessment (FBA) (97151), adaptive behavioral treatment by protocol or protocol modification (97153, 97155), and telehealth caregiver training (97156,… full guide →
Source ↗Timely filing is 120 days from the date of service (or per the provider agreement); corrected claims must be submitted within 90 days of the Explanation of Payment. Claims route through Availity Essentials, Highmark's exclusive EDI clearinghouse partner (payer ID 00246), or by paper to New York Claims, P.O. Box 61010, Virginia Beach, VA 23466-1010. Medical appeals of an… full guide →
Source ↗New York's autism mandate did once carry an explicit ABA ceiling. DFS described it plainly in 2014: the mandate "includes coverage for 680 hours of applied behavior analysis ('ABA') treatment per policy or calendar year per covered individual diagnosed with ASD." That sentence lived in the statute itself, in §§ 3216(i)(25)(B), 3221(l)(17)(B) and 4303(ee)(2) — not in a… full guide →
Source ↗Anthem's own provider FAQ told New York providers that most communications would move to the Anthem brand beginning January 1, 2024, that members would get a new ID card with the Anthem logo but the member ID number would not change, and that existing agreements and contracts with Empire were unaffected. So an Empire card in a family's folder is an Anthem card; do not treat it… full guide →
Source ↗Three sections, three markets § 3216(i)(25) binds individual accident and health policies; § 3221(l)(17) binds group or blanket policies; § 4303(ee) binds Article 43 corporations and HMOs. Between them they cover essentially every state-regulated New York plan. No age limit, no dollar cap, no hour cap The current text carries none of the three. The original 2011 law had a… full guide →
Source ↗New York licenses two credentials through the State Education Department: Licensed Behavior Analyst (LBA) and Certified Behavior Analyst Assistant (CBAA), the latter working under LBA supervision. NYSED is explicit that BACB certification "may be included in advertising in New York State" but "may not be used as a license to practice in New York State," and the grandparenting… full guide →
Source ↗Anthem reviews ABA itself — there is no delegated behavioral health vendor in the New York commercial path we could find, and Carelon Medical Benefits Management's New York programme is cardiology, genetic testing, radiology, musculoskeletal, surgical and radiation therapy, not ABA. The instrument is Anthem's Treatment Plan Request Form for Autism Spectrum Disorders, a… full guide →
Source ↗NMAC 8.321.2.13 and Supplement 24-13 cover two populations: recipients 12 months and older with a well-documented ASD diagnosis, and recipients with a well-documented risk for developing ASD — the at-risk pathway, for children roughly 12–36 months with developmental delays, some ASD characteristics, and a genetic risk factor such as an older sibling with ASD or Fragile X.… full guide →
Source ↗The state fee schedule marks 97151, 97152, and 0362T "Prior Auth: NO" — so once eligibility is verified, the Stage 2 assessment can be booked immediately, no authorization packet required. Adults can access Stage 2 without PA as well (a CDE is not required for adults unless medically warranted). PA lands essentially only on treatment: 97153 (adaptive behavior treatment by… full guide →
Source ↗New Mexico publishes credential-tiered ABA rates, flagged with modifiers: U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician — explicitly allowed with or without a bachelor's degree). Per 15-minute unit, effective 1/1/2025: 97151 pays $130.94 (U5/U4) and $112.65 (U3); 97153 pays $38.02 / $37.99 / $32.31 / $23.35 / $19.85 down the tiers;… full guide →
Source ↗Turquoise Care launched July 1, 2024 with four MCOs: Blue Cross and Blue Shield of New Mexico, Molina (new to the state), Presbyterian Health Plan, and UnitedHealthcare Community Plan (also new, with ABA administered by Optum). Non-MCO recipients run fee-for-service, with MAD's Third-Party Assessor handling authorizations. Clinically the MCOs defer to the state's NMAC criteria… full guide →
Source ↗New Mexico still has no behavior analyst license as of mid-2026 — the state is absent from the BACB's licensure table — so Medicaid credentialing runs entirely on certification plus MAD attestations, with dedicated provider types: BCBAs/BCBA-Ds enroll individually as Provider Type 445, Specialty 099 via the MAD-877 attestation (current BACB certificate attached; any… full guide →
Source ↗The clinical baseline is the state's: the shared Level of Care Guidelines' ABA Stage 3 section references NMAC 8.321.2 throughout, so eligibility (ASD or at-risk), the stage model, and the no-PA assessment front door match the New Mexico Medicaid guide. The BCBSNM layer is the ABA Clinical Service Request Form for treatment — 5 pages, initial and concurrent versions — with the… full guide →
Source ↗BCBSNM's line-staff (1:1 technician) requirements are concrete: 18 or older, HS diploma or GED, background check, 40 hours of ASD/evidence-based-practice training, and BCBA oversight of at least 5% of direct hours — worth checking against your tech roster before submitting. The member handbook excludes ABA for educational, vocational, respite, or custodial purposes, so frame… full guide →
Source ↗Clinically, expect the state baseline: the ASD-or-at-risk eligibility, no-PA assessment, the 97153 treatment PA, and the service-authorization-plus-6-month-PA cadence all come from the state program (see the New Mexico Medicaid guide). Presbyterian's contribution is its paperwork: Stage 3 treatment requests go on Presbyterian's own ABA Clinical Review Form (with a separate… full guide →
Source ↗Presbyterian contracts Magellan for behavioral health on its Medicare and commercial lines — but Turquoise Care (Medicaid) behavioral health is handled in-house. An ABA authorization for a Medicaid member routed to Magellan goes nowhere: use the Medicaid-specific BH fax (505) 843-3019 or the Turquoise Care portal submission. Because the same family can move between… full guide →
Source ↗Verified: Molina is a Turquoise Care MCO bound by the state's ABA criteria and the LOD #53 rate floor, its provider manual requires electronic PA submission, and Availity Essentials is the mandated primary channel (a contract-compliance item, not a preference). Not verified: any Molina-specific ABA clinical policy, PA form, or code-level PA list for New Mexico — we found none… full guide →
Source ↗Whatever Molina's internal mechanics turn out to be, two things are anchored at the state level and enforceable: the clinical criteria (NMAC 8.321.2.13 and Supplement 24-13 — the ASD-or-at-risk eligibility, adult benefit, stage model, and authorization cadence) and the rates. Letter of Direction #53 directs every Turquoise Care MCO to pay providers no less than the Medicaid… full guide →
Source ↗The Quick Reference Guide is unambiguous: all autism services are PA-free except 97153 (adaptive behavior treatment by protocol) and 0373T. That means the 97151 assessment, 97155 protocol modification, and 97156 family training all proceed without authorization — so the only PA workflow to build for UHC members is the treatment request. It goes on the New Mexico Uniform Prior… full guide →
Source ↗ABA runs on Optum's dedicated network, so credentialing and case questions live on Provider Express, not the standard UHC medical channels — tech support and chat at 1-866-209-9320, claim status at 1-888-702-2202. All autism services bill on a CMS-1500 to Payer ID 87726 (ERA 86047) via uhcprovider.com, with paper claims to Optum, PO Box 31348, Salt Lake City, UT 84131-0348.… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗New Mexico's mandate is one of the stronger ones in our directory. NMSA 1978 § 59A-22-49 (with parallel sections for HMOs and nonprofit health plans) requires any individual or group policy delivered, issued, or renewed in the state to cover ASD screening plus treatment — naming applied behavioral analysis alongside speech, occupational, and physical therapy, per a… full guide →
Source ↗We checked: Aetna publishes no New Mexico-specific ABA policy, form, or supplement — the national Clinical Policy Bulletins plus the state mandate is the whole picture, and Aetna runs no Medicaid plan in New Mexico. That's worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where New Mexico-specific answers come… full guide →
Source ↗New Mexico has no behavior analyst licensure law — BCBAs practice on BACB certification alone, with no state board at the Regulation & Licensing Department. (On the Medicaid side, the state adds an HCA practitioner attestation and background check, but that's a program requirement, not licensure.) On rates: Aetna does not publish commercial ABA fee schedules for New Mexico… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗New Mexico's mandate is one of the stronger ones in our directory. NMSA 1978 § 59A-22-49 (with parallel sections for HMOs and nonprofit health plans) requires any individual or group policy delivered, issued, or renewed in the state to cover ASD screening plus treatment — naming applied behavioral analysis alongside speech, occupational, and physical therapy, per a… full guide →
Source ↗We ran a full-text check of the current EN0499 (effective 5/15/2026): it contains no New Mexico mention or carve-out — unlike Virginia, where the policy excludes fully-insured business. New Mexico Cigna members follow the standard EN0499 criteria unless their plan documents differ, which means the no-assessment-PA fast path holds here. Cigna runs no Medicaid plan in New… full guide →
Source ↗New Mexico has no behavior analyst licensure law — BCBAs practice on BACB certification alone, with no state board at the Regulation & Licensing Department. (On the Medicaid side, the state adds an HCA practitioner attestation and background check, but that's a program requirement, not licensure.) On rates: Cigna does not publish commercial ABA fee schedules for New Mexico… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗New Mexico's mandate is one of the stronger ones in our directory. NMSA 1978 § 59A-22-49 (with parallel sections for HMOs and nonprofit health plans) requires any individual or group policy delivered, issued, or renewed in the state to cover ASD screening plus treatment — naming applied behavioral analysis alongside speech, occupational, and physical therapy, per a… full guide →
Source ↗We checked Optum's national ABA State Mandates supplemental criteria document (BH 803ABA, effective January 2026) in full: it lists Arizona, California, Connecticut, Florida, Massachusetts, New Jersey, New York, Ohio, and Pennsylvania — no New Mexico entry, so no NM-specific supplemental criteria modify the commercial policy. Where Optum IS deeply invested in New Mexico is… full guide →
Source ↗New Mexico has no behavior analyst licensure law — BCBAs practice on BACB certification alone, with no state board at the Regulation & Licensing Department. (On the Medicaid side, the state adds an HCA practitioner attestation and background check, but that's a program requirement, not licensure.) On rates: UnitedHealthcare does not publish commercial ABA fee schedules for New… full guide →
Source ↗The Behavioral Health Services Manual states that participants enrolled in a MO HealthNet Managed Care health plan receive ABA services on a FFS basis, outside the managed-care benefit package — and the plans corroborate it in their own documents. Healthy Blue's provider manual lists ABA among services "reimbursed by the state agency on a fee-for-service basis," and the Show… full guide →
Source ↗All ABA services require precertification — the manual's sole exception is school-based ABA delivered under an IEP. The mechanics are refreshingly analog: complete the "Applied Behavior Analysis Request for Precertification" form (form 2575-045) and fax it to the MHD Behavioral Health Services help desk at (573) 635-6516. The state reviews in-house and faxes back the approved… full guide →
Source ↗Missouri pays by rendering-practitioner tier, flagged with modifiers: HO = behavior analyst or psychologist, HN = assistant behavior analyst, HM = behavior technician/RBT (billed by the licensed supervisor), U8 = home or other place of service, TM = telemedicine. Per 15-minute unit from the official fee schedule: 97151 assessment pays $25.26 (max 32 units); 97153 direct… full guide →
Source ↗Missouri made the national RBT credential mandatory with a 90-day grace period: a behavior technician (18+, high-school diploma, 40-hour RBT training, passed initial competency assessment) may render services for up to 90 calendar days from passing the competency assessment, but must pass the national RBT exam and hold the BACB credential by day 90 to continue — effective… full guide →
Source ↗At the technician level, Missouri layers almost nothing on the BACB — because it delegated the whole credential: 13 CSR 70-98.030 requires technicians to be "credentialed by the Behavior Analyst Certification Board (BACB) as a Registered Behavior Technician," with no state-registry alternative, and the April 1, 2024 policy adds the age/education floor (18+, high-school diploma… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. Aetna publishes no… full guide →
Source ↗Missouri's mandate — enacted by 2010's HB 1311, with the current version applying to plans delivered, issued, continued, or renewed on or after January 1, 2020 (which added developmental and physical disability coverage) — reaches unusually far: beyond ordinary individual and group policies, it covers the state consolidated health care plan, self-insured governmental plans,… full guide →
Source ↗Missouri requires behavior-analyst licensure: RSMo 337.315 prohibits practicing applied behavior analysis without an LBA (or Licensed Assistant Behavior Analyst) license or an enumerated exception — supervised trainees, licensed psychologists within scope, IDEA school personnel, and students among them. The Behavior Analyst Advisory Board within the State Committee of… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. And unlike some states,… full guide →
Source ↗Missouri's mandate — enacted by 2010's HB 1311, with the current version applying to plans delivered, issued, continued, or renewed on or after January 1, 2020 (which added developmental and physical disability coverage) — reaches unusually far: beyond ordinary individual and group policies, it covers the state consolidated health care plan, self-insured governmental plans,… full guide →
Source ↗Missouri requires behavior-analyst licensure: RSMo 337.315 prohibits practicing applied behavior analysis without an LBA (or Licensed Assistant Behavior Analyst) license or an enumerated exception — supervised trainees, licensed psychologists within scope, IDEA school personnel, and students among them. The Behavior Analyst Advisory Board within the State Committee of… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. Notably, Missouri has no entry in… full guide →
Source ↗Missouri's mandate — enacted by 2010's HB 1311, with the current version applying to plans delivered, issued, continued, or renewed on or after January 1, 2020 (which added developmental and physical disability coverage) — reaches unusually far: beyond ordinary individual and group policies, it covers the state consolidated health care plan, self-insured governmental plans,… full guide →
Source ↗A family saying "we have UnitedHealthcare" in Missouri may be on UnitedHealthcare Community Plan of Missouri — one of the four MO HealthNet Managed Care plans. But here Missouri differs from most states: Medicaid ABA is fully carved out of managed care to state fee-for-service, so UHC (and Optum) plays no role in Missouri Medicaid ABA authorization or payment. For those… full guide →
Source ↗Missouri requires behavior-analyst licensure: RSMo 337.315 prohibits practicing applied behavior analysis without an LBA (or Licensed Assistant Behavior Analyst) license or an enumerated exception — supervised trainees, licensed psychologists within scope, IDEA school personnel, and students among them. The Behavior Analyst Advisory Board within the State Committee of… full guide →
Source ↗The statute reads: "Coverage provided under this section for applied behavior analysis shall be subject to a maximum benefit of forty thousand dollars per calendar year for individuals through eighteen years of age. Such maximum benefit limit may be exceeded, upon prior approval by the health benefit plan, if the provision of applied behavior analysis services beyond the… full guide →
Source ↗Missouri shares one commercial precertification list with Indiana, Kentucky, Ohio and Wisconsin. Under behavioral health services it lists, for MO Blues products, all facility-based care, inpatient admissions, intensive outpatient therapy, partial hospitalization, residential care, ECT, transcranial magnetic stimulation, applied behavioral analysis and intensive in-home… full guide →
Source ↗If you have an older playbook that says Anthem reviews ABA under clinical guideline CG-BEH-02, retire it. Anthem told commercial providers that "effective June 1, 2024, Anthem will transition from CG-BEH-02 (Adaptive Behavioral Treatment) and MCG W0153 (Behavioral Health Care Applied Behavioral Analysis), to MCG B-806-T Behavioral Health Care Applied Behavioral Analysis… full guide →
Source ↗A six-month ceiling on plan review Outside inpatient services, the statute gives the carrier the right to review the treatment plan "not more than once every six months" unless the carrier and the treating physician or psychologist agree more frequent review is necessary — and the cost of obtaining any review or treatment plan is borne by the plan, not the provider. If an… full guide →
Source ↗From March 1, 2026, Anthem reimburses ABA in Missouri on weekly approved units rather than total authorized units. Claims should reflect the units rendered within each week up to the approved weekly limit; units above it are ineligible for reimbursement and get adjusted. Existing requests and claims, including those with date ranges running past the effective date, are… full guide →
Source ↗Missouri is unusual in tying the insurance mandate directly to the state license. An "autism service provider" under § 376.1224 is either a person or entity licensed or certified by the state of Missouri, or a person "licensed under chapter 337 as a board-certified behavior analyst by the behavior analyst certification board or licensed under chapter 337 as an assistant… full guide →
Source ↗Autism Services is an EPSDT benefit: THSteps-CCP covers medically necessary ABA for members from birth through age 20, with eligibility ending on the 21st birthday. The gate is an ASD diagnosis — but not any diagnosis, from anyone, at any time. The TMPPM requires the diagnosis to come from a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an… full guide →
Source ↗Everything is prior-authorized. The ABA evaluation (97151, limited to 24 units / 6 hours per evaluation, billed with the HO modifier by the LBA) needs a PA that includes a signed referral from the prescribing provider plus the diagnosis documentation, submitted on the CCP Prior Authorization Request Form. Treatment then authorizes in two consecutive 90-day periods — the… full guide →
Source ↗HHSC raised ABA rates roughly 11.5% across the board effective September 1, 2025 — the first adjustment since the benefit launched. Per 15-minute unit: 97151 evaluation pays $27.56 (was $24.71); 97153 direct treatment by a behavior technician pays $14.50 (was $13.00); 97155 protocol modification pays $20.08–$25.10 and 97156 family training $18.40–$23.01, tiered by credential… full guide →
Source ↗Direct treatment is capped at 8 hours (32 units) per day combined across 97153, 97154, 97155, and 97158. Telehealth (synchronous audio-visual, modifier 95) is allowed for 97151, 97155, 97156, 97158, and 99366 — but 1:1 direct treatment delivered by a BT or LaBA must be in person; no telehealth. Interdisciplinary team meetings are billable under 99366 with an ABA PA on file. On… full guide →
Source ↗Texas certifies behavior technicians but doesn't license them. The TMPPM (§ 2.3.6.3) requires every BT to hold one of three certifications — RBT, BCAT, or ABAT — so the RBT is accepted but explicitly not the only pathway. BTs may not enroll in Texas Medicaid (they render under the enrolled LBA), may not use "therapist" in their job title when interacting with Medicaid… full guide →
Source ↗Superior announced the ABA benefit at its February 2022 launch with prior authorization required on every service code — 97151 for the evaluation, then 97153, 97154, 97155, 97156, 97158, and 99366 for treatment and team meetings — and its notices defer to the TMPPM for medical-necessity criteria, so the state's 3-year diagnosis recency, 90/90/180 cadence, and 8-hour daily cap… full guide →
Source ↗If your practice serves children in foster care, Superior is unavoidable: STAR Health is administered by Superior alone, statewide. That makes Superior credentialing and PA fluency a de facto requirement for foster-care ABA anywhere in Texas — and it means intake should treat "foster care" as a routing answer, not just a demographic note. The clinical rules are the same TMPPM… full guide →
Source ↗TCHP's evaluation PA wants a referral that documents the child's age, the year of the initial ASD diagnosis, comorbidities and trauma history, and DSM symptom severity — with the diagnosis made or reconfirmed within the past 3 years, per the state rule. Requests go to the UM Department via the electronic authorization portal, fax, phone, or mail; electronic signatures are… full guide →
Source ↗TCHP sells CHIP alongside its Medicaid lines, and the ABA benefit does not extend to CHIP — the exclusion is explicit in both the state benefit and TCHP's guideline. For intake, that means "we have Texas Children's" isn't enough: confirm the child is on STAR or STAR Kids, not CHIP, before quoting the ABA pathway. A CHIP family's options are commercial-style coverage rules, not… full guide →
Source ↗The assessment PA needs a completed treatment-request form — Wellpoint accepts either its own "Treatment Plan Request Form for Autism Spectrum Disorders" or the state CCP Prior Authorization Request Form — plus a current, signed physician ABA referral and the clinical documentation the TMPPM requires. If your practice standardizes on the state CCP form across payers, Wellpoint… full guide →
Source ↗Wellpoint's provider doc spells out the billing edges that mirror the TMPPM: 97151 is capped at 24 units (6 hours) per evaluation; direct treatment caps at 8 hours per day; the credential-modifier table governs claims; LaBAs and BTs may not deliver via telehealth; and — explicitly — no separate reimbursement for treatment planning or report writing outside 97151, and no… full guide →
Source ↗UHC's STAR Kids medical prior-authorization list (effective 11/1/2025) does not contain ABA codes 97151–97158 — and a provider who reads that as "no PA needed" is walking into denials. The codes are missing because behavioral health services are carved out to the plan's designated behavioral network, administered by Optum: ABA authorization requests go through that BH pipeline… full guide →
Source ↗Optum's national ABA supplemental clinical criteria document (BH803ABA) lists state-specific overlays for a handful of states — and Texas is not one of them. With no distinct plan policy either, the TMPPM governs Medicaid medical necessity for UHC members exactly as it does everywhere else in Texas: same diagnoser list, same recency rule, same hour caps, same telehealth… full guide →
Source ↗Every fact on the Texas Medicaid guide applies to Aetna Better Health members: PA required on the 97151 evaluation (24-unit cap) with a signed prescriber referral and an ASD diagnosis made or reconfirmed within 3 years; treatment authorized in two 90-day periods then 180-day recertifications, with the prescriber signature no longer required on the 90-day extension since April… full guide →
Source ↗We could not verify Aetna Better Health of Texas's ABA-specific submission mechanics from public sources — the plan's provider manual and Medicaid pages return errors to automated retrieval, and no distinct TX ABA policy surfaced elsewhere. Aetna Better Health plans typically run submissions through Availity, but treat that as an assumption, not a fact. Before your first case:… full guide →
Source ↗Molina members get the same benefit as everyone else in Texas Medicaid: PA on the 97151 evaluation with signed prescriber referral and a 3-year-recent ASD diagnosis, the 90/90/180 treatment cadence (no prescriber signature on the 90-day extension since April 2025), the 8-hour daily cap, credential modifiers, and the in-person requirement for BT/LaBA-delivered direct treatment.… full guide →
Source ↗Molina directs providers to its Behavioral Health and Medical Prior Authorization Code Matrix / Look-Up Tool for code-level PA handling, and its current-year "MHT Prior Authorization Guide" PDF is the document of record — but those files sit behind bot protection, so we could not verify their ABA specifics for this guide. Before your first Molina submission: download the… full guide →
Source ↗Community First's published guidelines make the state's billing mechanics concrete: 97151 "is not reimbursable unless evaluation was submitted for authorization of payment," capped at 24 units per period; treatment codes 97153, 97154, 97155, 97156, and 97158 plus team-meeting code 99366 are all PA-gated; direct treatment caps at 8 hours / 32 units per day combined; and the… full guide →
Source ↗The clinical rulebook is the state's: F84.0 diagnosis mandatory, ages 0 through 20, the TMPPM's PA cadence, and rates referencing 1 TAC § 355 and the Texas Medicaid fee schedule (no plan-specific rates published). Authorizations run through the Community First provider portal. Because the plan is a TMPPM digest rather than a second rulebook, a practice that has its… full guide →
Source ↗Autism (ABA) Services appear on Driscoll's Prior Authorization Requirement Portal (driscollhealthplan.com/priorauthcheck) — the plan's own tool for verifying PA requirements code by code, which is the right first stop before any submission. Requests submit through the DHP portal or by fax to 1-866-741-5650 using the Texas Authorization Referral Form. Because the TARF is the… full guide →
Source ↗Everything on the Texas Medicaid guide applies unchanged: PA on the 97151 evaluation (24-unit cap), the April 2025 removal of the prescriber signature on 90-day extensions, the 3-year diagnosis recency rule, the 8-hour daily direct-treatment cap, credential modifiers, and the telehealth restrictions. Driscoll's only plan-specific wrinkle is workflow — verify the code on the… full guide →
Source ↗CHC's guideline names the Texas Medicaid Provider Procedures Manual, Children's Services Handbook §2 Autism Services, as its governing authority and states it "represents the minimum requirements to determine medical necessity for ABA services." It lists 97151, 97153, 97154, 97155, 97156, and 97158 explicitly (0362T and 99366 are not mentioned in CHC's own document — rely on… full guide →
Source ↗CHC's 90-day extension and 180-day recertification requests both require an attendance log for the child and the parent/caregiver, plus a progress summary signed by the BCBA (LBA) and the parent — and CHC states members/caregivers are "expected to attend at least 85% of scheduled sessions"; falling below that threshold requires the ABA therapist to document why and what… full guide →
Source ↗CHC's STAR quick reference guide confirms both target counties — Harris and Jefferson — are served under STAR. Its STAR+PLUS quick reference guide, however, lists only Harris (and eight other counties) — Jefferson does not appear on the STAR+PLUS list, consistent with the "Applies To" gap noted above. CHIP is excluded from ABA entirely, per CHC's own HHS Provider Manual ("CHIP… full guide →
Source ↗As late as a 7/5/2023-dated PA summary, BCBSTX directed providers to "contact Magellan for authorization requirements" for Texas Medicaid behavioral health — a classic BH carve-out. On May 10, 2024, BCBSTX announced the "insourcing of Behavioral Health Services for Medicaid," and every current-generation document we could find (the ABA PA Requirement Checklist, revised… full guide →
Source ↗BCBSTX's Texas Medicaid Benefit Prior Authorization Procedure Code List lists 97151, 97153, 97154, 97155, 97156, and 97158 each as "Applied Behavioral Health (Allowable only for members 20 years of age or younger)," PA-required, effective 1/1/2024 — matching the statewide code set. We could not find 0362T or 99366 on this list or any other BCBSTX Medicaid document; treat their… full guide →
Source ↗Cook Children's own training confirms the statewide code set with granular billing notes: 97151 (evaluation/re-evaluation) caps at 6 hours/24 units with a 30-day authorization window and takes the HO modifier only; 97153 and 97154 (direct and group treatment) take no required modifier (HO/HN/HM are informational); 97155, 97156, and 97158 require an HO or HN modifier; and 99366… full guide →
Source ↗Cook Children's runs authorization through an EpicCare Link secure provider portal, and its determination letters are delivered only through the portal's In Basket — the plan states explicitly that PA determination letters will not be faxed. Fax submission (STAR/CHIP: 682-885-8402; STAR Kids: 682-303-0005 or 844-843-0005) is offered only for providers whose portal access is… full guide →
Source ↗PCHP's Prior Authorization Requirements document (effective September 1, 2025) states plainly: "Prior authorization is required for ABA evaluation, initial course of treatment, and subsequent re-evaluations for recertification." Its code table lists 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, and 99366 explicitly under an "Applied Behavior Analysis" category —… full guide →
Source ↗PCHP announced it was "transitioning Behavioral Health services from Carelon effective Sept. 1, 2025," with providers required to contract and credential directly with PCHP to remain in-network for behavioral health, and new member ID cards issued with updated BH information. PCHP's own 218-page provider manual, last revised September 2024, still describes "Carelon and PCHP… full guide →
Source ↗El Paso Health's ABA Request Checklist (effective 2/1/2022) lays out each PA stage: the initial evaluation (97151, capped at 6 hours/24 units, HO modifier only) needs a signed prescriber referral and comprehensive diagnostic documentation, and the resulting authorization is valid for 60 days from the requested evaluation date; the initial 90-day treatment request needs the… full guide →
Source ↗PA requests submit through the DHP-style provider portal at secure.healthx.com/elpasoprovider, or by fax (outpatient/scheduled: 915-298-7866 or 1-844-298-7866) or phone (915-532-3778 or 1-877-532-3778 for STAR/CHIP; 1-833-742-3127 for STAR+PLUS). El Paso Health accepts the Texas Standard Prior Authorization Request Form, its own "Request for Behavioral Health Services" form,… full guide →
Source ↗FirstCare's STAR & CHIP Notification/Prior Authorization Codes list (effective 7/1/2026) lists 97151, 97153, 97154, 97155, 97156, 97158, and 99366 as requiring authorization, filed under "Therapy services" rather than behavioral health. Notably absent from that Medicaid-specific list: 97152, 97157, 0362T, and 0373T — those four codes appear only in FirstCare's separate… full guide →
Source ↗Requests submit through the myFirstCare Self-Service Portal (my.firstcare.com/Web) or by fax using the Texas Standard Prior Authorization Request Form — FirstCare uses the statewide form, not a proprietary one. General turnaround is 3 working days from receipt of complete clinical information, and the plan asks providers to submit at least 5 days before the anticipated service… full guide →
Source ↗TMHP's July 17, 2026 announcement states Baylor Scott & White (MRSA Central) and FirstCare Health Plans (MRSA West/Lubbock) will end participation in Texas Medicaid managed care, with the final date of service TMHP will accept being August 31, 2026; claims with a date of service on or after September 1, 2026 will be rejected, and providers have until August 31, 2028 (24… full guide →
Source ↗RightCare's own Medicaid/CHIP Prior Authorization Codes list (effective 7/1/2026) confirms PA-required ABA codes 97151, 97153, 97154, 97155, 97156, 97158, and 99366 — each showing a PA-requirement effective date of 1/3/2020 — with 97152 and 97157 absent from the list, matching the TMHP statewide THSteps-CCP Autism Services code set exactly. Requests submit through the… full guide →
Source ↗RightCare runs behavioral health administration itself, under the branded units "RightCare Behavioral Health Management" and "RightCare Behavioral Health Disease and Case Management" (phone 1-855-395-9652, fax 1-844-436-8779) — no third-party BH vendor (no Cenpatico, Beacon, Magellan, Carelon, or Optum) appears anywhere in the plan's current provider manual or PA materials.… full guide →
Source ↗RightCare's own 2025/2026 network materials list a 30-county MRSA Central service area: Bell, Blanco, Bosque, Brazos, Burleson, Colorado, Comanche, Coryell, Erath, Falls, Fayette, Freestone, Gillespie, Gonzales, Grimes, Hamilton, Hill, Jackson, Lampasas, Lavaca, Leon, Limestone, Llano, Madison, McLennan, Milam, Mills, Robertson, San Saba, and Washington. A separate internal… full guide →
Source ↗Dell Children's Health Plan's own provider manual states it plainly: "Dell Children's Health Plan has been an administrator of CHIP since 2000 and was selected to administer the CHIP Perinatal and STAR programs in Central Texas beginning March 1, 2012." It currently publishes actively-maintained documents dated into 2026 (a Prior Authorization list effective 6/1/2026, provider… full guide →
Source ↗The plan's STAR Member Handbook and provider manual both explicitly list "Applied Behavior Analysis (ABA) therapy" as a covered STAR behavioral-health service, and the member-facing behavioral-health page states ABA "is now a benefit for STAR members as a covered benefit through Texas Medicaid," requiring prior ASD diagnostic testing "by a developmental pediatrician, a… full guide →
Source ↗Unlike some Texas MCOs that handle BH in-house, Dell Children's Health Plan delegates behavioral-health services — including ABA-related prior authorization and referrals — to Magellan Healthcare. The member-facing behavioral-health page tells families to "self-refer directly by calling Magellan toll-free at 1-800-424-1764," and the provider manual lists dedicated… full guide →
Source ↗Dell Children's Health Plan lists a value-added benefit directly relevant to autism families: the GoManda learning app, free for one year to CHIP/STAR members ages 2 to 8 with autism or speech delay, available with a referral. It's not a substitute for ABA, but it's worth mentioning at intake as a no-cost supplement families may not know they have access to. No dedicated… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Texas's mandate — Tex. Ins. Code § 1355.015, enacted by HB 1919 in 2007 and expanded several times since — applies to group health benefit plans (group policies, HMOs, group hospital service contracts, and TRS school-employee plans), and it has a structure intake teams must internalize: coverage runs from the date of diagnosis, but only if the ASD diagnosis was in place before… full guide →
Source ↗A family saying "we have Aetna" in Texas may actually be on the carrier's Medicaid plan — Aetna Better Health of Texas (STAR, STAR Kids, and CHIP in the Bexar and Tarrant service areas) — which follows the state Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan. Note also that we… full guide →
Source ↗Texas has required licensure to practice ABA since 2018: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the Behavior Analyst Licensing Act (Occupations Code Chapter 506), administered by the Texas Department of Licensing and Regulation (TDLR) with BACB certification as the backbone — family members implementing plans and… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. And unlike some states, Texas… full guide →
Source ↗Texas's mandate — Tex. Ins. Code § 1355.015, enacted by HB 1919 in 2007 and expanded several times since — applies to group health benefit plans (group policies, HMOs, group hospital service contracts, and TRS school-employee plans), and it has a structure intake teams must internalize: coverage runs from the date of diagnosis, but only if the ASD diagnosis was in place before… full guide →
Source ↗Unlike Aetna and UnitedHealthcare, Cigna has no Texas Medicaid plan to cross-wire with: its Texas Medicaid (STAR+PLUS) contracts were sold to Molina Healthcare in 2021, and its 2025 sale to HCSC covered Medicare businesses only. A "Cigna Medicaid" mention in Texas today means Molina — route those families to the Molina guide. Every genuine Cigna card in Texas is commercial (or… full guide →
Source ↗Texas has required licensure to practice ABA since 2018: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the Behavior Analyst Licensing Act (Occupations Code Chapter 506), administered by the Texas Department of Licensing and Regulation (TDLR) with BACB certification as the backbone — family members implementing plans and… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. Notably, Optum's "ABA State Mandates" supplemental criteria document has no Texas entry — we verified the… full guide →
Source ↗Texas's mandate — Tex. Ins. Code § 1355.015, enacted by HB 1919 in 2007 and expanded several times since — applies to group health benefit plans (group policies, HMOs, group hospital service contracts, and TRS school-employee plans), and it has a structure intake teams must internalize: coverage runs from the date of diagnosis, but only if the ASD diagnosis was in place before… full guide →
Source ↗A family saying "we have UnitedHealthcare" in Texas may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of Texas (STAR, STAR Kids, CHIP) — which follows the state TMPPM rules with ABA carved out to Optum's behavioral health network, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the… full guide →
Source ↗Texas has required licensure to practice ABA since 2018: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the Behavior Analyst Licensing Act (Occupations Code Chapter 506), administered by the Texas Department of Licensing and Regulation (TDLR) with BACB certification as the backbone — family members implementing plans and… full guide →
Source ↗ABA is an EPSDT service for MassHealth Standard and CommonHealth members under 21 (under 19 on Family Assistance), with coverage driven by medical necessity — no annual or lifetime dollar caps, no unit-of-service limits. Historically the diagnosis gate was autism: a comprehensive assessment aligned with DSM criteria across the core ASD deficits, completed by a licensed… full guide →
Source ↗MassHealth managed care is a lattice of 15 Accountable Care Partnership Plans, 2 Primary Care ACOs, 2 MCOs, and the PCC Plan (roster per the April 2023 state deck; the current lineup — including Steward Health Choice's status after Steward's collapse, and the Tufts Health Together MCO's discontinuation effective 1/1/2026 — should be re-verified). What matters operationally is… full guide →
Source ↗MassHealth audited CY2024 encounter data across all six ABA-administering plans and, via Carelon, issued recoupment letters in February–March 2026 enforcing a minimum 1:10 supervision ratio — one hour of protocol modification (97155) for every ten hours of direct treatment (97153). Ratios of 10:1 to 19:1 drew partial recoupment; 20:1 and beyond drew full recoupment of… full guide →
Source ↗101 CMR 358.03 pays a single rate per code — no credential-tier modifiers; each rate is "full compensation" including necessary administration and professional supervision. Per 15-minute unit: 97151, 97155, and 97156 at $30.73; 97153 at $16.37 (about $65.48/hour); 97154 at $13.91; 97157 at $26.12 — effective September 27, 2024 (published as the October 1, 2024 schedule). EOHHS… full guide →
Source ↗Massachusetts does not require RBT certification for technicians — and has no state registry or license for them. Under the Carelon/MBHP ABA performance specification (updated February 15, 2026), a Behavior Technician must be 18 or older, work under the direct supervision of a Licensed Applied Behavior Analyst (LABA), and meet one of three pathways: a high school diploma or… full guide →
Source ↗MBHP essentially is the state program: it applies MassHealth's criteria and the multi-payer Massachusetts Standard ABA PA Form — initial evaluation, initial services, continued services, and amendment request types, completed by the LABA rendering or supervising services — with authorizations in up to 6-month periods. Submissions run through Carelon's ProviderConnect portal… full guide →
Source ↗When MassHealth enforced its CY2024 supervision-ratio audit — the 1:10 floor of 97155 to 97153, with recoupment letters in February–March 2026 — Carelon was the administrator that ran the analysis and issued the letters. For practices billing MBHP that means the scrutiny is not hypothetical: keep the supervision hours on the schedule and in the claims at 1:10 or better, and… full guide →
Source ↗As of January 1, 2026, ABA for WellSense's MassHealth plans is authorized by WellSense's own in-house behavioral-health team, not Carelon — WellSense assumed BH administration for all Massachusetts products on that date (claims for dates of service before 1/1/2026 still route to Carelon for run-off). Requests still use the Massachusetts Standard ABA PA Form — WellSense hosts… full guide →
Source ↗A family may name their ACO — Boston Children's ACO, Mercy, Signature, Tufts Medicine Care Alliance — without ever saying "WellSense," so intake should map ACPP names to the WellSense flow rather than treating each as a separate payer. All eight ACPPs plus the Essential MCO run the same ABA machinery. Since the 1/1/2026 insourcing, that machinery is WellSense's own UM rather… full guide →
Source ↗Per the October 2025 provider update, Tufts Health Together adopted InterQual criteria with InterQual SmartSheets for ABA prior-authorization review, with a new ABA medical-necessity guideline effective January 1, 2026 — and moved members onto Point32Health's own updated ABA PA form. Requests submit electronically with the form uploaded, or by fax to 888-977-0776. For a… full guide →
Source ↗Point32Health is rolling out an ABA provider accreditation requirement — accreditation by a nationally recognized ABA accrediting body — across its Harvard Pilgrim and Tufts Health Plan products, making accreditation a network-participation gate, not a quality nicety. Budget the accreditation timeline into any Tufts network strategy. Worth knowing on the enforcement front:… full guide →
Source ↗Fallon has no published ABA criteria of its own — its MassHealth plans defer to Carelon's UM on the state-baseline rules: PA required for assessment and treatment on the Massachusetts Standard ABA PA Form, authorizations in 6-month periods, no published hour caps, medical necessity per EPSDT. Plan-level submission specifics (including whether Fallon requests route through… full guide →
Source ↗First, the roster: the 2023 ACPP lineup may have shifted — Atrius's ownership changes in particular make the Fallon-Atrius entry worth confirming before onboarding a family who names it. Second, the audit: Fallon is named among the six ABA-administering plans in MassHealth's CY2024 supervision-ratio audit and received recoupment letters in the first wave, so the 1:10… full guide →
Source ↗BeHealthy Partnership members carry an HNE card, but ABA requests go to MBHP: the standard PA form (initial evaluation, initial services, continued services), 6-month authorization periods, submissions through providers.masspartnership.com. No HNE-specific ABA criteria, forms, or hour caps exist — the state baseline governs, including the Down syndrome pathway from January 1,… full guide →
Source ↗HNE is named among the six ABA-administering plans in MassHealth's CY2024 supervision-ratio audit and received first-wave recoupment letters — so BeHealthy claims sit under the same 1:10 97155-to-97153 enforcement as the rest of the MBHP/Carelon universe. Schedule supervision hours accordingly and reconcile the ratio before continuation requests.
Source ↗Optum's ABA State Mandates supplement carries a Massachusetts Medicaid entry effective October 1, 2021: for Early Intervention members, ABA services should not exceed 30 hours per week, and BCBA-to-paraprofessional supervision must run at 1:10 — with the supervisor and technician possibly both required to be present during home visits. No cap is stated for non-EI members,… full guide →
Source ↗Because behavioral health is carved to Optum, expect the Optum toolkit — Provider Express is Optum's standard portal, though its use for this plan specifically isn't published, so confirm the submission channel with the plan before the first request. Authorization cadence follows the statewide practice of roughly 6-month periods. Clinically, requests are reviewed against… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗ARICA — An Act Relative to Insurance Coverage for Autism, Chapter 207 of the Acts of 2010, codified at M.G.L. c. 175 § 47AA and parallel sections for HMOs, service corporations, and GIC state-employee plans — is one of the strongest autism mandates in the country. Since January 1, 2011, fully-insured plans must cover the diagnosis and treatment of ASD with no age limits and no… full guide →
Source ↗Unusually for a national carrier, Aetna hosts and uses the Massachusetts Standard Form for Applied Behavior Analysis Services Prior Authorization Requests — the same multi-payer form the MassHealth world runs on: completed by the LABA, with request types for initial evaluation, initial services, continued services, and amendments, and an authorization period not to exceed 6… full guide →
Source ↗Massachusetts licenses behavior analysts as Licensed Applied Behavior Analysts (LABA), with an assistant tier (LAABA), through the Board of Registration of Allied Mental Health and Human Services Professions — under M.G.L. c. 112 as amended by Chapter 429 of the Acts of 2012, with requirements at 262 CMR 10.00, built on BCBA certification. The state's payers key the ABA… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗ARICA — An Act Relative to Insurance Coverage for Autism, Chapter 207 of the Acts of 2010, codified at M.G.L. c. 175 § 47AA and parallel sections for HMOs, service corporations, and GIC state-employee plans — is one of the strongest autism mandates in the country. Since January 1, 2011, fully-insured plans must cover the diagnosis and treatment of ASD with no age limits and no… full guide →
Source ↗We checked the current EN0499 (effective 5/15/2026) end to end: it contains no Massachusetts-specific provision — its only state carve-out is Virginia fully-insured business. So Massachusetts Cigna members get the standard EN0499 machinery, including the no-PA assessment fast path, with ARICA layered on top for fully-insured plans: where the national policy and the mandate… full guide →
Source ↗Massachusetts licenses behavior analysts as Licensed Applied Behavior Analysts (LABA), with an assistant tier (LAABA), through the Board of Registration of Allied Mental Health and Human Services Professions — under M.G.L. c. 112 as amended by Chapter 429 of the Acts of 2012, with requirements at 262 CMR 10.00, built on BCBA certification. Massachusetts payers key the ABA… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. That clinical policy is national — what changes in Massachusetts is the legal floor underneath it: ARICA governs… full guide →
Source ↗ARICA — An Act Relative to Insurance Coverage for Autism, Chapter 207 of the Acts of 2010, codified at M.G.L. c. 175 § 47AA and parallel sections for HMOs, service corporations, and GIC state-employee plans — is one of the strongest autism mandates in the country. Since January 1, 2011, fully-insured plans must cover the diagnosis and treatment of ASD with no age limits and no… full guide →
Source ↗Massachusetts appears twice in Optum's ABA State Mandates supplement (BH 803ABA STM12026, effective January 2026). First, for Massachusetts Medicaid Early Intervention members (effective 10/1/2021): ABA services should not exceed 30 hours per week, and BCBA-to-paraprofessional supervision must run at 1:10 — with supervisor and technician possibly both required present during… full guide →
Source ↗UnitedHealthcare runs no MassHealth MCO or ACPP of its own — but Optum, its behavioral arm, administers the ABA benefit for the Mass General Brigham Health Plan MassHealth ACPP, which has its own guide. UHC's Massachusetts Medicaid-linked products — UnitedHealthcare Connected for One Care (ages 21–64) and Senior Care Options (65+) — serve adult populations, so they carry… full guide →
Source ↗Massachusetts licenses behavior analysts as Licensed Applied Behavior Analysts (LABA), with an assistant tier (LAABA), through the Board of Registration of Allied Mental Health and Human Services Professions — under M.G.L. c. 112 as amended by Chapter 429 of the Acts of 2012, with requirements at 262 CMR 10.00, built on BCBA certification. Massachusetts payers key the ABA… full guide →
Source ↗For years Florida ran BA as a fee-for-service carve-out with all prior authorization through eQHealth (now Acentra Health). SMMC 3.0 ended that on February 1, 2025: BA moved into the nine MMA plans — Aetna Better Health, Children's Medical Services Health Plan, Community Care Plan, Florida Community Care, Humana Healthy Horizons, Molina, Simply Healthcare, Sunshine Health, and… full guide →
Source ↗Florida's eligibility test is functional, not diagnostic: recipients under 21 "requiring medically necessary BA services to address behavior that impairs a recipient's ability to perform a major life activity" — safety, communication, self-care, self-stimulating and other behaviors all qualify. There is no F84.x requirement. What gates entry instead is a referral from an… full guide →
Source ↗All BA services require prior authorization — assessment included. On the FFS side, assessment requests (97151, 97152, 97151-TS) are submitted separately from treatment codes in eQSuite; initial ("admission") requests go in at least 5 business days before the start date, reauthorizations ("continued stay") 10–30 business days before the current period ends, with decisions in 3… full guide →
Source ↗The January 1, 2025 BA fee schedule (still operative through 2026) pays per 15-minute unit: 97151 behavior assessment $19.05 (max 24 units per assessment; reassessment 97151-TS $19.05, max 18 units), 97153 direct treatment $12.26 (RBT, BCaBA, or Lead Analyst — same rate regardless of credential), 97155 protocol modification $19.17 at the Lead Analyst tier ($15.37 with the HN… full guide →
Source ↗Florida licenses no behavior analysts: s. 393.17, F.S. instead recognizes certification from a national credentialing board — the BACB — and the FL-CBA is a closed legacy credential (the BACB absorbed the old state program in October 2003; no new FL-CBAs are issued, and a lapsed one requires requalifying as a BCBA). Under the December 2024 coverage policy, technicians must be… full guide →
Source ↗Requests go through the Sunshine Health Secure Provider Portal or by fax to the dedicated BA line, 1-844-208-9113, using Sunshine's BA PA request form. The documentation requirements are the state stack: Vineland-3 and BASC-3 PRQ scoring reports at the initial assessment and annually, the physician referral/order/CDE gate, and 6-month authorization periods. Determinations land… full guide →
Source ↗Sunshine runs a value-based incentive program for BA providers with outcome-tied bonuses — worth asking about at contracting, since it's the only one of the nine plans with a published BA VBP. On the flip side: industry reporting describes a temporary pause, effective October 1, 2025, on enrolling new practitioners into existing BA provider groups — effectively a network… full guide →
Source ↗Sunshine Health's own newsroom describes Centene's Florida footprint as spanning several separate lines of business: "Sunshine Health offers government-sponsored managed care through Medicaid, Long Term Care, the Health Insurance Marketplace (Ambetter), and Medicare (Allwell)." Ambetter from Sunshine Health is the ACA Health Insurance Marketplace (exchange) brand — a… full guide →
Source ↗Everything mechanical about CMS Health Plan BA is Sunshine Health: the Secure Provider Portal, the BA PA request form, the dedicated BA fax at 1-844-208-9113, in-house UM, and the AHCA clinical criteria underneath (referral + order + CDE, Vineland-3/BASC-3 reports, 6-month authorizations). The two differences worth building into intake: determinations take up to 7 calendar… full guide →
Source ↗Effective February 1, 2025, Simply's BA authorizations run through Carelon Behavioral Health — submit via the Carelon eServices portal or fax 1-800-370-1116 — and claims submit to Carelon through Availity Essentials (Carelon's preferred direct-data-entry channel), with Payspan handling payments. At the transition, existing authorizations were auto-extended at least 90 days for… full guide →
Source ↗Carelon requires that the treatment plan and supporting data be no older than 30 days at the time of PA submission. That's a process rule, not a coverage limit — the state's 6-month reassessment cycle still governs clinically — but it changes sequencing: don't finalize the behavior plan months ahead of the submission date, and when a renewal window opens, refresh data… full guide →
Source ↗All BA services require prior authorization, and requests must be submitted via the secure Provider Express portal (One Healthcare ID login): Auths → Request a new authorization → select "ABA Assessment" or "ABA Treatment" from the dropdown. That two-step, assessment-then-treatment structure is Optum's national ABA pattern, applied to the Florida Medicaid population — with the… full guide →
Source ↗At the carve-in, UHC committed to a 120-day continuity-of-care period from February 1, 2025 — honoring and extending existing Acentra authorizations for the full 120 days and paying non-participating providers at prior rates for a minimum of 60 days. That window has closed; every auth now lives in Provider Express. Claims go to UHC Community Plan under payer ID 87726 with… full guide →
Source ↗PA is required for all BA services and can be initiated three ways: Availity Essentials (Humana's preferred channel), the 24/7 IVR at 800-523-0023, or fax to 813-321-7220, using the Florida ABA PA form (MCD 466). The documentation list tracks the state policy closely: the Comprehensive Diagnostic Evaluation, the physician's order, the BASC-3 PRQ for ages 2–18 (at initial… full guide →
Source ↗Participating providers bill at contracted rates (claims via Availity, payer ID 61101; paper to Humana's Lexington, KY claims office), with clean claims processed within 20 days. The notable rate fact: for codes inside an approved authorization, non-participating claims default-pay at a percentage of the Florida Medicaid allowable fee schedule — an explicit statutory-schedule… full guide →
Source ↗To join ABHFL's BA network, providers contract and credential through Behavioral Services Network, Inc. (BSN) — info@bsnnet.com, 305-907-7470 — a distinct entry point from Aetna's own credentialing machinery and from every other Florida plan. For a group planning multi-plan participation, BSN is a separate pipeline to start early. Once in network, ABHFL publishes a set of… full guide →
Source ↗The AHCA coverage policy binds ABHFL like every MMA plan: PA on all BA services, the referral + order + CDE gate (no autism diagnosis required), Vineland-3/BASC-3 documentation, and up-to-6-month authorizations that the plan cannot make more stringent. Plan notices indicate ABHFL ran extended carve-in continuity into mid-2025, with universal PA applying to all members… full guide →
Source ↗Verified: Molina administers BA in-house since the February 1, 2025 carve-in, maintains a BA Quick Reference Guide (updated October 2025, with a 2026 edition), and — like every MMA plan — must comply with the AHCA coverage policy without imposing more stringent limits. That gives you the dependable core: PA on all BA services with the CDE and required documentation, the… full guide →
Source ↗CCP's BA manual is direct: behavior assessments, reassessments, and all codes on the Florida BA Fee Schedule require prior authorization by Therapy Network. Requests go through the Provider Web Portal at asp.healthsystemone.com/hs1providers (fax available as backup), and approvals and claims status run 24/7 on therapynetwork.com — claims themselves also go to TNFL, with paper… full guide →
Source ↗CCP's coverage criteria and exclusions track the AHCA policy nearly verbatim: the referral + order + CDE gate with no autism-diagnosis requirement, Vineland-3/BASC-3 documentation, up-to-6-month authorizations, and the 40-hour weekly ceiling as prior-authorized. The operative difference is purely who you talk to — for intake, that means TNFL portal credentials are the day-one… full guide →
Source ↗Submit the Florida Community Care ABA Prior Authorization Request Form to the in-house Utilization Department by fax (305-675-6138), email (FCCUMDepartment@FCCHealthPlan.com — email PA submission is unusual among Florida's plans and handy for small teams), or through the FCC Provider Portal at secure.healthx.com. The clinical criteria are the state's: referral + order + CDE at… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗The Steven A. Geller Autism Coverage Act (2008) requires coverage in group plans issued or delivered in Florida after April 1, 2009 — in practice fully-insured large-group plans and the state employee plan under § 627.6686, with companion § 641.31098 reaching large-group HMO contracts. It explicitly excludes individual-market, individually underwritten, and small-employer… full guide →
Source ↗A family saying "we have Aetna" in Florida may actually be on the carrier's Medicaid plan — Aetna Better Health of Florida, one of the nine SMMC MMA plans administering Behavior Analysis since February 2025 — which follows the state Medicaid rules (no autism diagnosis required), not this commercial policy. Verify which line of business the card belongs to, and use the… full guide →
Source ↗Florida has no state behavior-analyst license — it is absent from the BACB's list of states with licensure laws. The operative credential is BACB certification (BCBA/BCaBA/RBT); s. 393.17, Fla. Stat. requires the state to recognize BACB certification, and legacy Florida Certified Behavior Analysts (FL-CBA, administered by BACB since 2003) remain recognized — the Geller Act… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗The Steven A. Geller Autism Coverage Act (2008) requires coverage in group plans issued or delivered in Florida after April 1, 2009 — in practice fully-insured large-group plans and the state employee plan under § 627.6686, with companion § 641.31098 reaching large-group HMO contracts. It explicitly excludes individual-market, individually underwritten, and small-employer… full guide →
Source ↗We checked the current EN0499 text directly: it contains no Florida mention and no Florida carve-out — unlike Virginia, where the policy excludes fully-insured business, Florida members are handled under the standard EN0499 criteria (ASD diagnosis F84.0–F84.9 required, F84.2 excluded), subject to any controlling state mandate at the benefit-plan level. That means the… full guide →
Source ↗Florida has no state behavior-analyst license — it is absent from the BACB's list of states with licensure laws. The operative credential is BACB certification (BCBA/BCaBA/RBT); s. 393.17, Fla. Stat. requires the state to recognize BACB certification, and legacy Florida Certified Behavior Analysts (FL-CBA, administered by BACB since 2003) remain recognized — the Geller Act… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. That clinical policy is national — what changes in Florida is the legal floor underneath it: the state mandate… full guide →
Source ↗The Steven A. Geller Autism Coverage Act (2008) requires coverage in group plans issued or delivered in Florida after April 1, 2009 — in practice fully-insured large-group plans and the state employee plan under § 627.6686, with companion § 641.31098 reaching large-group HMO contracts. It explicitly excludes individual-market, individually underwritten, and small-employer… full guide →
Source ↗Florida has its own entry in Optum's ABA State Mandates supplemental criteria (policy BH 803ABA STM12026, effective January 2026): for Florida members on mid- and large-group fully-insured plans (not individual or small-group), ABA is covered for the treatment of Down syndrome, and speech, physical, and occupational therapy plus ABA must be covered to the same extent as the… full guide →
Source ↗A family saying "we have UnitedHealthcare" in Florida may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of Florida, whose Behavior Analysis program Optum has managed since the February 2025 SMMC carve-in. That plan follows the state Medicaid rules (no autism diagnosis required, portal-only PA on Provider Express), not this commercial policy.… full guide →
Source ↗Florida has no state behavior-analyst license — it is absent from the BACB's list of states with licensure laws. The operative credential is BACB certification (BCBA/BCaBA/RBT); s. 393.17, Fla. Stat. requires the state to recognize BACB certification, and legacy Florida Certified Behavior Analysts (FL-CBA, administered by BACB since 2003) remain recognized — the Geller Act… full guide →
Source ↗ABA moved from the old HCBS Autism waiver into the Medicaid State Plan under EPSDT effective January 1, 2017, split into two services. CCTS ("Autism Specialist Services," provider type 11, specialty 403) is the analyst tier — billed under 97151, 97152, 97155, and 97156 — and carries an approved soft limit of 50 hours per year. IIS (specialty 404) is the technician-delivered… full guide →
Source ↗KanCare is comprehensive statewide managed care — effectively all ~458,000 beneficiaries sit with one of three MCOs under contracts running 1/1/2025 through 12/31/2027 (renewable to 2029): Sunflower Health Plan (Centene), UnitedHealthcare Community Plan (behavioral health via Optum), and Healthy Blue Kansas, the new entrant. Aetna Better Health of Kansas, which served KanCare… full guide →
Source ↗At the state-policy level, CCTS — which includes the assessment function, now billed 97151 — requires a recommendation by a physician or other licensed practitioner and is subject to prior authorization; each MCO operates its own PA intake. The tripwire to design intake around is diagnosis recency: both Sunflower (KS.CP.01) and Optum/UHC (BH 803ABA Kansas entry) require that… full guide →
Source ↗We won't quote current Kansas autism-services rates, because we couldn't verify them. The last public anchor is the CPT crosswalk effective 1/1/2019, which set 97151 at $17.50 per 15-minute unit — and that was then raised effective 4/1/2019 by a bulletin that did not publish the new amounts. Notably, the 7/1/2022 behavioral-health rate increase did NOT include the 9715x autism… full guide →
Source ↗Kansas is one of the few states where RBT certification is genuinely optional for Medicaid work. Since April 3, 2020, IIS technicians (KMAP type 11, specialty 404, billing 97153) qualify one of two ways: hold an RBT certificate, or complete the state-equivalent pathway — age 18+, high-school diploma or equivalent, 40 hours of ABA training including 8 hours of supervised… full guide →
Source ↗KS.CP.01 drives authorization off a fully completed Autism Authorization Request Form with a dated provider signature, and the packet is specific: a physician recommendation or prescription; the original autism diagnosis validated within the last 6 months by an MD or licensed psychologist; a criterion-referenced standardized assessment (Vineland-3, ADOS, CARS, ADI-R, GARS, or… full guide →
Source ↗Medicaid members must have a current Kan Be Healthy (EPSDT) screen completed within the past year by a physician, APRN, PA, or credentialed RN — and the policy is explicit that this is not the same as a well-child exam (the requirement is waived for Ambetter members). Families often need a PCP visit before ABA can be approved, which makes screen status a day-one intake… full guide →
Source ↗Optum's Kansas Medicaid entry codifies the state EPSDT framework with its own supplement: the member must be age 20 and under with an ASD diagnosis validated within the last 6 months by a licensed psychologist or MD via comprehensive diagnostic evaluation; identified deficits form the basis of an individualized treatment plan of no more than 40 hours per week; the CCTS… full guide →
Source ↗You cannot start with Optum directly: providers complete KMAP enrollment first, and Optum then retrieves the application from KMAP to begin credentialing (about 60 days). CCTS credentialing requires both BACB certification proof AND the Kansas BSRB license number. Auth resources live on Provider Express; the contracting line is 1-877-614-0484 (ask for the Kansas ABA Network… full guide →
Source ↗Prior authorization submits through Availity (Patient Registration > Authorizations & Referrals), or by phone or fax — behavioral-health outpatient fax 1-866-852-8978 (inpatient 1-866-852-8976) — and the site hosts a Prior Authorization Lookup Tool for code-level questions. Autism and psychological testing use distinct paper forms: the Autism Spectrum Disorder Testing request… full guide →
Source ↗We found no published Kansas-specific ABA hour caps, review cadence, or diagnosis-recency rule for Healthy Blue — the biggest verification gap among the three MCOs. Until the plan publishes more, work from the KanCare baseline (CCTS 50 hours/year, IIS 25 hours/week initial, state PA requirement) and confirm specifics through Availity or the ABA line before promising families a… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Kansas's mandate, K.S.A. 40-2,194, is one of the narrower ones in our directory. It reaches large-group policies, service-corporation contracts, fraternal benefit societies, and HMOs (issued/renewed after 1/1/2015; grandfathered plans from 1/1/2016), and 2023's SB 24 redefined "large employer" down to 51+ employees. Coverage is limited to covered individuals under age 12, and… full guide →
Source ↗Unlike many states, "we have Aetna" in Kansas cannot mean Medicaid anymore: Aetna Better Health of Kansas served KanCare from 2019 to 2024, lost the KanCare 3.0 contract, and its members auto-transitioned to Healthy Blue Kansas on January 1, 2025. Any directory, card, or family memory pointing at Aetna Better Health of Kansas is stale — route those inquiries to the Healthy… full guide →
Source ↗Kansas has required licensure for practicing behavior analysts since July 1, 2016: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the applied behavior analysis licensure act (K.S.A. 65-7501 et seq.), administered by the Behavioral Sciences Regulatory Board and keyed to BACB certification — and the mandate itself conditions… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Kansas's mandate, K.S.A. 40-2,194, is one of the narrower ones in our directory. It reaches large-group policies, service-corporation contracts, fraternal benefit societies, and HMOs (issued/renewed after 1/1/2015; grandfathered plans from 1/1/2016), and 2023's SB 24 redefined "large employer" down to 51+ employees. Coverage is limited to covered individuals under age 12, and… full guide →
Source ↗We checked the current EN0499 line by line: it contains no Kansas entry and no Kansas carve-out — the national criteria apply in Kansas, subject to the standard proviso that state law and the plan contract can override. Cigna also operates no Medicaid plan in Kansas, so a Cigna card here is always commercial. That makes benefits verification (plan funding type, mandate… full guide →
Source ↗Kansas has required licensure for practicing behavior analysts since July 1, 2016: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the applied behavior analysis licensure act (K.S.A. 65-7501 et seq.), administered by the Behavioral Sciences Regulatory Board and keyed to BACB certification — and the mandate itself conditions… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Kansas's mandate, K.S.A. 40-2,194, is one of the narrower ones in our directory. It reaches large-group policies, service-corporation contracts, fraternal benefit societies, and HMOs (issued/renewed after 1/1/2015; grandfathered plans from 1/1/2016), and 2023's SB 24 redefined "large employer" down to 51+ employees. Coverage is limited to covered individuals under age 12, and… full guide →
Source ↗Optum's ABA State Mandates supplemental criteria document does contain an explicit Kansas section — but it is a "For Kansas Medicaid member" section, codifying the KanCare CCTS/IIS rules (age 20 and under, 6-month diagnosis validation, 40 hours/week plan ceiling, monthly progress reviews, 6-month renewals, and an exclusion list). It governs UnitedHealthcare Community Plan of… full guide →
Source ↗A family saying "we have UnitedHealthcare" in Kansas may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of Kansas, a KanCare MCO with behavioral health run by Optum — which follows the state's CCTS/IIS Medicaid rules, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Source ↗Kansas has required licensure for practicing behavior analysts since July 1, 2016: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the applied behavior analysis licensure act (K.S.A. 65-7501 et seq.), administered by the Behavioral Sciences Regulatory Board and keyed to BACB certification — and the mandate itself conditions… full guide →
Source ↗Admission requires a diagnosis of ASD or a developmental or intellectual disability — plus significant functional impairment in at least two listed domains — when the need for ABA is established by the ABA behavior identification assessment. That makes Nebraska one of the states where intake should not turn away a family without an autism diagnosis: ask about developmental and… full guide →
Source ↗Effective August 1, 2025, DHHS cut ABA reimbursement dramatically — roughly 28–79% by code per CASP's estimate — after program spend grew from $4.6M in 2020 to more than $85M in 2024, a >2,000% increase DHHS cites on its own ABA Facts page. The current schedule per 15-minute unit: 97151 assessment $38.16, 97153 direct treatment $18.70, 97155 protocol modification $22.72, 97156… full guide →
Source ↗Prior authorization runs through the member's MCO. The treatment MSD requires the ABA assessment and treatment plan to be submitted with the initial prior authorization request, and Provider Bulletin 25-02 clarifies that PA duration is "based on medical necessity and therefore is variable in duration" — no fixed statewide authorization period. Separately from whatever the MCO… full guide →
Source ↗Since January 1, 2025, every BCBA serving Nebraska Medicaid must hold a Nebraska Licensed Behavior Analyst (LBA) license (BCaBAs a LaBA license); an LBA may supervise at most 24 technicians, must directly observe at least 10% of weekly direct-service hours, and must personally deliver at least 1 hour per month of in-person direct service. Caregiver participation is a tracked… full guide →
Source ↗At the technician level, Nebraska is now a pure-BACB state. Under the treatment MSD, the only staff who may deliver 97153/97154 under a licensed clinician are RBTs with current BACB certification or Licensed assistant Behavior Analysts (LaBAs) — and PB 25-02 dropped the state's longstanding bachelor's-degree-plus-experience requirement for RBTs, leaving BACB certification plus… full guide →
Source ↗ABA requests go through the Outpatient Treatment Request (OTR) process — the plan publishes an ABA Form and an ABA OTR Tip Sheet — submitted through the secure provider portal (provider.nebraskatotalcare.com) or by fax to 866-593-1955. The treatment plan must include hours requested per service with clinical justification, billing codes, a titration/discharge plan, a crisis… full guide →
Source ↗The policy's documentation checklist is unusually granular: time in/out, pauses in service with resume times, even preferred-versus-legal name conventions. Paired with the plan's published tip-sheet suite (assessment/plans, caregiver training, coordination of care, transition planning), the signal is active chart auditing — build session-note templates to the checklist rather… full guide →
Source ↗Molina's Nebraska Medicaid PA page establishes the machinery: requests submit through Availity Essentials (preferred), by fax to (833) 832-1015, or by phone at (844) 782-2678, with a Behavioral Health Certification of Need for Services form published for BH services and quarterly PA code-change PDFs posted for the current year. What it does not establish is an ABA-specific… full guide →
Source ↗Molina took over from Healthy Blue on January 1, 2024 under a five-year contract (with a two-year option), alongside Nebraska Total Care and UnitedHealthcare. Its ABA utilization management is done in-house — the plan hires Nebraska-based "Care Review Clinician, ABA" roles requiring an LBA license — so expect clinical conversations with licensed analysts rather than a… full guide →
Source ↗Optum's Nebraska program requires prior authorization for everything: the initial ABA assessment (including write-up time) needs a written request — the treatment request form marked as an assessment request — with the diagnostic evaluation, IDI, or FBA attached. Treatment is a second, separate authorization: families cannot start treatment on the assessment auth alone.… full guide →
Source ↗Optum runs the ABA network separately from the medical plan — verify benefits via the behavioral-health number on the member ID card or the NMES line at 1-800-642-6092, not the medical line. Per Optum's program documents, eligibility is described as members younger than 20 covered under Heritage Health. Treatment requests probe school hours and parent participation, and expect… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Nebraska's mandate (LB 254 of 2014, effective for policies delivered or renewed on or after January 1, 2015) requires coverage of screening, diagnosis, and treatment of ASD for individuals under 21 — with behavioral health treatment including ABA capped at a maximum benefit of 25 hours per week until age 21. No visit limits or less-favorable dollar limits or cost-sharing are… full guide →
Source ↗We checked: Aetna publishes no Nebraska-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, the 25-hour cap's presence in the plan document) is where Nebraska-specific answers come from, not a carrier document.
Source ↗Nebraska licenses behavior analysts under the Behavior Analyst Practice Act (Neb. Rev. Stat. § 38-4401 et seq., regulations at 172 NAC 86): the Licensed Behavior Analyst (LBA) credential for BCBAs and LaBA for BCaBAs, administered by the DHHS Licensure Unit with a Board of Behavior Analysts — and since January 1, 2025 the state's Medicaid program requires the license of every… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is… full guide →
Source ↗Nebraska's mandate (LB 254 of 2014, effective for policies delivered or renewed on or after January 1, 2015) requires coverage of screening, diagnosis, and treatment of ASD for individuals under 21 — with behavioral health treatment including ABA capped at a maximum benefit of 25 hours per week until age 21. No visit limits or less-favorable dollar limits or cost-sharing are… full guide →
Source ↗We checked: the current EN0499 contains no Nebraska carve-out or mention — its state-mandate language cites New York only as an example — so Nebraska commercial members are handled under the standard national policy, subject to the § 44-7,106 mandate on state-regulated plans. That's worth knowing in itself: it means benefits verification (plan funding type, mandate… full guide →
Source ↗Nebraska licenses behavior analysts under the Behavior Analyst Practice Act (Neb. Rev. Stat. § 38-4401 et seq., regulations at 172 NAC 86): the Licensed Behavior Analyst (LBA) credential for BCBAs and LaBA for BCaBAs, administered by the DHHS Licensure Unit with a Board of Behavior Analysts — and since January 1, 2025 the state's Medicaid program requires the license of every… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national —… full guide →
Source ↗Nebraska's mandate (LB 254 of 2014, effective for policies delivered or renewed on or after January 1, 2015) requires coverage of screening, diagnosis, and treatment of ASD for individuals under 21 — with behavioral health treatment including ABA capped at a maximum benefit of 25 hours per week until age 21. No visit limits or less-favorable dollar limits or cost-sharing are… full guide →
Source ↗A family saying "we have UnitedHealthcare" in Nebraska may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of Nebraska (Heritage Health), whose ABA network Optum has managed since 2017 — which follows the state Medicaid rules and the Optum Medicaid workflow, not this commercial policy. Verify which line of business the card belongs to, and use the… full guide →
Source ↗Nebraska licenses behavior analysts under the Behavior Analyst Practice Act (Neb. Rev. Stat. § 38-4401 et seq., regulations at 172 NAC 86): the Licensed Behavior Analyst (LBA) credential for BCBAs and LaBA for BCaBAs, administered by the DHHS Licensure Unit with a Board of Behavior Analysts — and since January 1, 2025 the state's Medicaid program requires the license of every… full guide →
Source ↗Utah's four ACOs handle physical health, and for autism-diagnosed members they also handle ASD-related PT, OT, and speech — but ABA and the autism diagnostic evaluation are carved out to state fee-for-service. The manual states that mental health evaluations and psychological testing for diagnosing developmental disorders are carved out of the managed-care entities and… full guide →
Source ↗The manual is explicit: ABA therapy requires prior authorization — but that requirement 'does not apply to initial or ongoing behavior identification assessments.' The live PRISM lookup confirms it: 97151 shows 'Prior Authorization Required? No,' limited to one assessment per 26 weeks at up to 24 units, with reassessment roughly every 6 months. So with a diagnosis in hand,… full guide →
Source ↗Utah publishes its ABA rates in the PRISM coverage lookup. Effective July 1, 2026, per 15-minute unit: 97153 direct treatment pays $19.67, and 97151, 97155, and 97156 all pay $37.51 — 97155 reported with a credential modifier (HP psychologist/BCBA-D, HO BCBA, HN BCaBA/analyst-in-training) but a single published rate across tiers. The caps are generous: 97153 up to 780 hours… full guide →
Source ↗Per the July 2026 Medicaid Information Bulletin (item 26-61), Utah has reclassified ABA providers as 'High Risk' for enrollment screening. Every existing ABA provider must revalidate within 18 months, with notices phased starting September 2026 — and revalidation now includes individual ownership reporting and fingerprint-based background checks. Failure to complete within 60… full guide →
Source ↗The January 2026 ASD manual update removed the technician on-ramp: behavior technicians must be fully certified before performing any services for a Utah Medicaid member — the manual states there is 'no grace period granted between a technician's initial hire date and the date in which the technician receives certification,' ending the prior policy that allowed a 40-hour… full guide →
Source ↗Select Health's own Medicaid Provider Summary describes SelectHealth Community Care as one of three government/managed products it runs alongside Select Health Medicare and Select Health Share, "available to eligible members living in all Utah counties." Its Provider Reference Manual separately defines a "Fee-For-Service Medicaid member" as anyone whose needed service is… full guide →
Source ↗For employer-group, self-funded, and individual/marketplace members, Select Health runs its own numbered medical policy — Policy #630, "Applied Behavior Analysis (ABA)" — which Select Health's February 2026 Policy Update Bulletin confirms was revised effective January 1, 2026 (the bulletin describes reorganized medical-necessity criteria and removal of an FEHB-plan exception,… full guide →
Source ↗Select Health's ABA Preauthorization Form routes requests by email, split cleanly by line of business: commercial (large/small employer, self-funded, individual) goes to commercialUMintake@imail.org (fax 801-442-0825); Select Health Community Care (Medicaid/CHIP) goes to medicaidUMintake@imail.org (fax 801-442-0625) — relevant only for the non-ABA services Community Care still… full guide →
Source ↗Utah Code § 31A-22-642 requires ASD diagnosis-and-treatment coverage in the individual and large-group markets — small-group plans are not named by the statute. Select Health's own ABA Preauthorization Form lists "Commercial Plans (Large/Small Employer, Self-Funded, Ind.)" as a single routing category, meaning Select Health's ABA intake process is unified across market… full guide →
Source ↗No Select Health-specific ABA fee schedule (commercial or Community Care) was found published. For Community Care members, ABA rides Utah Medicaid FFS entirely, so the relevant benchmark is Utah Medicaid's own published PRISM rates ($19.67 per 15-minute unit on 97153; $37.51 on 97151/97155/97156, effective 7/1/2026) — not a Select Health rate at all. For commercial members,… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is… full guide →
Source ↗Utah Code § 31A-22-642 requires coverage for the diagnosis and treatment of autism spectrum disorder in the individual and large-group markets — small group plans are not named by the statute, making market segment the load-bearing question in Utah, even ahead of funding type. For plans entered or renewed on or after January 1, 2020 there is no age limit and no cap on covered… full guide →
Source ↗We checked: Aetna publishes no Utah-specific ABA policy, form, or supplement — CPB 0648 contains no Utah entry, and Aetna's standard language defers to state mandates for fully-insured plans. The national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (market segment, plan funding type, mandate applicability)… full guide →
Source ↗Utah requires a license to practice behavior analysis: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LABA) credentials under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7), administered by the Division of Professional Licensing (DOPL). Behavior technicians work as certified paraprofessionals under QHP supervision… full guide →
Source ↗Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. And unlike Virginia — the one… full guide →
Source ↗Utah Code § 31A-22-642 requires coverage for the diagnosis and treatment of autism spectrum disorder in the individual and large-group markets — small group plans are not named by the statute, making market segment the load-bearing question in Utah, even ahead of funding type. For plans entered or renewed on or after January 1, 2020 there is no age limit and no cap on covered… full guide →
Source ↗We checked: Cigna / Evernorth publishes no Utah-specific ABA policy, form, or supplement — EN0499 mentions Utah nowhere, and its only state exclusion is Virginia. The national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (market segment, plan funding type, mandate applicability) is where Utah-specific… full guide →
Source ↗Utah requires a license to practice behavior analysis: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LABA) credentials under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7), administered by the Division of Professional Licensing (DOPL). Behavior technicians work as certified paraprofessionals under QHP supervision… full guide →
Source ↗UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. Notably, Utah has no entry in Optum's ABA State Mandates supplemental criteria (the January 2026 edition lists… full guide →
Source ↗Utah Code § 31A-22-642 requires coverage for the diagnosis and treatment of autism spectrum disorder in the individual and large-group markets — small group plans are not named by the statute, making market segment the load-bearing question in Utah, even ahead of funding type. For plans entered or renewed on or after January 1, 2020 there is no age limit and no cap on covered… full guide →
Source ↗UnitedHealthcare holds no Utah Medicaid ACO contract, so unlike most states there is no UHC Community Plan to confuse a card with. The one place the name appears on the Medicaid side is United Behavioral Health (Optum), listed among Utah's Prepaid Mental Health Plan contractors — but PMHPs cover inpatient and outpatient mental health and SUD services only, and ABA is carved… full guide →
Source ↗Utah requires a license to practice behavior analysis: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LABA) credentials under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7), administered by the Division of Professional Licensing (DOPL). Behavior technicians work as certified paraprofessionals under QHP supervision… full guide →
Source ↗Idaho covers ABA-based treatment for children as Children’s Habilitation Intervention Services. The rule defines CHIS as "medically necessary, evidence-informed or evidence-based therapeutic techniques based on applied behavior analysis principles used to result in positive outcomes." The handbook says CHIS is "covered under the state plan and are not considered Home and… full guide →
Source ↗Eligibility is set by a screening, not a diagnosis. Under IDAPA 16.03.26.181, a need exists "when a deficit is identified in three (3) or more of the following areas: self-care; receptive and expressive language; learning; mobility; self-direction; capacity for independent living; economic self-sufficiency; or maladaptive behavior," with a deficit defined as "one-point-five… full guide →
Source ↗The rule is blunt: "All CHIS ordered on a participant's ACTP must be prior authorized by the Department," and providers must "obtain PA before delivering any CHIS." The initial ACTP and the screening are the exception and can be requested retroactively. Once the initial request is submitted, "CHIS may be delivered for a maximum of twenty-four (24) hours and up to thirty (30)… full guide →
Source ↗Idaho publishes CHIS rates by provider category and setting (effective September 1, 2025, last reviewed January 1, 2026). For Developmental Disability Agencies, individual Behavioral Intervention (H0004) pays $24.68 per 15 minutes for an EBM Intervention Professional (TG), $18.51 for an EBM Intervention Specialist (TF), $21.34 for an Intervention Professional (HO), $15.48 for… full guide →
Source ↗BCI’s Provider Administrative Policy PAP902 lists the behavioral health services that need prior authorization. ABA appears only as "Applied behavioral analysis (ABA) - requires PA for Federal Employee Program (FEP)," and "Requests for ABA for FEP members must meet medical necessity criteria as outlined in the InterQual criteria." The same policy warns that "Blue Cross of… full guide →
Source ↗Idaho is one of the few states with no autism insurance statute, and intake should say so plainly. What Idaho has instead is Department of Insurance Bulletin No. 18-02 (April 2, 2018). Reading the federal Mental Health Parity and Addiction Equity Act, ACA § 1557 and the state’s Essential Health Benefits together, the Department declared that it "will consider an exclusion of… full guide →
Source ↗Idaho has no behavior-analyst licensure law. It does not appear on the BACB’s list of states that license or regulate behavior analysts, so BACB certification is the working credential. Blue Cross of Idaho publishes no ABA fee schedule, and commercial rates are negotiated in your provider agreement. Idaho Medicaid’s published CHIS rates are a weak benchmark, because they use… full guide →
Source ↗BH18 applies to "member contracts with applicable benefits" subject to named state laws, including "Idaho’s Clarification Regarding Coverage of Treatments for Autism Spectrum Disorder (Bulletin No. 18-02)." It says a certified treating provider "in Idaho" is "a credentialed provider with a Board-Certified Behavioral Analysis (BCBA) certification issued by the Behavioral… full guide →
Source ↗Idaho is one of the few states with no autism insurance statute, and intake should say so plainly. What Idaho has instead is Department of Insurance Bulletin No. 18-02 (April 2, 2018). Reading the federal Mental Health Parity and Addiction Equity Act, ACA § 1557 and the state’s Essential Health Benefits together, the Department declared that it "will consider an exclusion of… full guide →
Source ↗Idaho has no behavior-analyst licensure law and is not on the BACB’s list of licensing states. That is why Regence’s policy defines the Idaho treating provider by BACB certification rather than a state license. Regence publishes no ABA fee schedule, and rates are negotiated in the provider agreement.
Source ↗Aetna’s precertification list for participating behavioral health providers (effective August 1, 2024) names every ABA code: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T. Requests go through Availity. The ABA medical necessity guide requires a DSM-5 ASD diagnosis (F84.0; F84.3–F84.9) "obtained by an appropriate provider," services "provided directly… full guide →
Source ↗Idaho is one of the few states with no autism insurance statute, and intake should say so plainly. What Idaho has instead is Department of Insurance Bulletin No. 18-02 (April 2, 2018). Reading the federal Mental Health Parity and Addiction Equity Act, ACA § 1557 and the state’s Essential Health Benefits together, the Department declared that it "will consider an exclusion of… full guide →
Source ↗Aetna’s guide requires services to be provided or billed by "licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists." Idaho has no licensure law and is not on the BACB’s list, so in Idaho the BCBA credential is what qualifies. Aetna publishes no commercial ABA rates, and they are negotiated in… full guide →
Source ↗The Evernorth autism resource guide removes prior authorization at the front door: "Prior authorization is no longer required for assessment CPT codes 97151, 97152, or 0362T with a diagnosis of autism," as long as the provider is independently licensed or a BCBA and the member’s policy covers ABA. Treatment requires the completed assessment and treatment plan attached to the… full guide →
Source ↗Idaho is one of the few states with no autism insurance statute, and intake should say so plainly. What Idaho has instead is Department of Insurance Bulletin No. 18-02 (April 2, 2018). Reading the federal Mental Health Parity and Addiction Equity Act, ACA § 1557 and the state’s Essential Health Benefits together, the Department declared that it "will consider an exclusion of… full guide →
Source ↗Idaho has no behavior-analyst licensure law and is not on the BACB’s list of licensing states, so in Idaho a BCBA qualifies under EN0499’s "Board Certified Behavior Analyst" category without a state license. Cigna publishes no commercial ABA rates, and they are negotiated in your agreement.
Source ↗Optum’s criteria state that "Prior authorization is required for ABA (unless otherwise specified or mandated by contract or law)." The Provider Express ABA page has providers "Request ABA assessment and treatment authorizations" in the portal, choosing "ABA Assessment or Treatment" for each request. The diagnosis must come from "a state licensed physician, psychologist, or… full guide →
Source ↗Idaho is one of the few states with no autism insurance statute, and intake should say so plainly. What Idaho has instead is Department of Insurance Bulletin No. 18-02 (April 2, 2018). Reading the federal Mental Health Parity and Addiction Equity Act, ACA § 1557 and the state’s Essential Health Benefits together, the Department declared that it "will consider an exclusion of… full guide →
Source ↗Idaho has no behavior-analyst licensure law and is not on the BACB’s list of licensing states, so Optum’s "Master- or Doctoral-level provider that is a Board-Certified Behavior Analyst" is the Idaho path. UnitedHealthcare publishes no commercial ABA rates, and they are negotiated in your agreement.
Source ↗Iowa treats ABA funding as a ladder, and the rungs are written into statute. Private coverage comes first, under the autism mandates at Iowa Code sections 514C.31 (large-group and non-state public-employee plans) and 514C.28 (State of Iowa employee plans). Medicaid covers the members it covers. The state Autism Support Program then catches the remainder: Iowa Code 225D.1… full guide →
Source ↗Iowa HHS's benefit comparison (Comm. 519, revised 03/2026) lists "Behavioral Health Intervention Services (BHIS), including applied behavior analysis" as Covered for Medicaid, Covered for the Iowa Health and Wellness Plan (residential treatment excepted), and "Not covered" for Hawki, Iowa's CHIP line. All three MCO manuals say the same thing: Wellpoint's September 2026 manual… full guide →
Source ↗Iowa Administrative Code 441—77.31 (renumbered from 77.26 when Iowa HHS re-adopted chapter 77 effective July 1, 2026) enrolls behavioral health providers in ten classes, three of which carry the ABA workforce: licensed behavior analysts, licensed assistant behavior analysts, and registered behavior technicians. The RBT class has a deliberately wide door: eligibility requires… full guide →
Source ↗Iowa's prior-authorization rule is now 441—79.9 (formerly 79.8; re-adopted effective July 1, 2026), and it opens by sending managed care away: it "governs requests for prior authorization for services not provided through an MCO. For services provided through an MCO, the prior authorization request is submitted, reviewed, and authorized by the MCO." For fee-for-service… full guide →
Source ↗Iowa's ABA rates are published. Rule 441—79.1 sets ABA's basis of reimbursement as the fee schedule, and the live Provider Type 62 (Behavioral Health) schedule, read on September 24, 2026, still carries the rates Informational Letter 2613-MC-FFS set on July 1, 2024 (a 5% increase, funded by 2024 Iowa Acts H.F. 2698) with no end date: 97151 $35.73 (HO/HP); 97152 $17.16 (HN) or… full guide →
Source ↗Iowa's rules do not define an ABA benefit of their own: neither chapter 78 nor the Behavioral Health Services and BHIS provider manuals contain ABA criteria. Iowa Total Care's manual points providers to "Iowa Medicaid guidelines published on Iowa HHS's Policy Clarification webpage" and to "Informational Letter IL1976". That letter, which should state the age range, diagnosis… full guide →
Source ↗The diagnosis must be a confirmed ASD per the current DSM "or an appropriate diagnosis as otherwise specified according to state-defined ABA criteria," established by "a licensed physician, psychologist, or other licensed professional with specialized training in diagnosis and treatment of ASD, or a provider otherwise authorized under state law/regulation," with the severity… full guide →
Source ↗CP.BH.104 sizes hours to the child and names a soft ceiling: treatment should "not exceed six hours per day up to a total of 30 hours per week" unless documentation shows the child's needs "cannot be adequately or effectively addressed" at less, and hours should be "less than 20 hours per week if attending school full-time." Protocol modification (97155) must occur "for at… full guide →
Source ↗Iowa Total Care prefers the Secure Provider Web Portal or Availity for behavioral health authorizations; the fallback is the state's uniform outpatient form 470-5595 faxed to Behavioral Health at 1-844-908-1170. Behavioral health outpatient services can be requested "up to 30 days in advance," and anything faxed or submitted after 8 a.m. to 6 p.m. Monday to Friday is processed… full guide →
Source ↗Iowa Total Care's September 2022 provider alert corrected pages 36–49 of its manual, which had shown BHIS and ABA as covered for Hawki members; that "was inaccurate." The state's March 2026 benefit comparison still lists BHIS "including applied behavior analysis" as not covered for Hawki. An Iowa Total Care member on the Medicaid line and one on the Hawki line have different… full guide →
Source ↗Wellpoint "accepts prior authorization requests via phone, fax or Interactive Care Reviewer (ICR), a secure utilization management tool available in Availity." For Medicaid behavioral health, the plan's prior-authorization page gives an inpatient fax of 1-844-442-8016 and an outpatient fax of 1-844-451-2826; the state's uniform outpatient form 470-5595 lists the same… full guide →
Source ↗We could not find a Wellpoint Iowa ABA clinical guideline, unit cap, supervision standard or telehealth position in the provider manual, the Clinical UM Guideline list (Nov. 2025), or the plan's public pages. The manual says criteria are available on request (providernetworkia@wellpoint.com, 833-731-2143). Until that document is in hand, the state rules on the Iowa Medicaid… full guide →
Source ↗Initiation requires a comprehensive assessment and a valid ASD diagnosis with every listed component: "ASD initiation age is 18 months or older"; "Documentation from the Member's primary care physician noting initial developmental concerns, screenings, referrals, and treatments provided"; DSM-5 or DSM-5-TR criteria including differentiation from Social Communication Disorder;… full guide →
Source ↗Molina encourages Availity Essentials for authorizations and accepts the uniform state form by fax at the Molina Iowa UM line, (877) 319-6828. The older quick reference guide still hosted by Iowa HHS (June 2023) lists a different medical PA fax, (319) 774-1295; use the 2026 manual and the prior-authorization page instead. The list of codes that need PA is the PA Codification… full guide →
Source ↗Iowa Code section 514C.31 requires a "group policy, contract, or plan" to cover "applied behavior analysis provided by a practitioner to covered individuals for the treatment of autism spectrum disorder pursuant to a treatment plan" when it is issued to an employer that employed "more than fifty full-time equivalent employees" on at least half its working days in the prior… full guide →
Source ↗Wellmark's public medical-policy index is an alphabetical list of medical policies; it contains no ABA policy. The page says InterQual criteria are used "to evaluate whether a medical procedure or equipment is medically necessary," and points to the Authorization Table as "your first stop in learning whether an authorization is required." Behavioral health rules live in the… full guide →
Source ↗Iowa licenses behavior analysts and assistant behavior analysts under Iowa Code chapter 154D, administered by the Board of Behavioral Health Professionals. A license is granted "upon submitting to the board proof of the applicant's current certification as a behavior analyst or behavior analyst-doctoral by a certifying entity" (the BACB or another NCCA- or ANSI-accredited… full guide →
Source ↗Aetna's ABA Medical Necessity Guide requires "a DSM-V diagnosis of Autism Spectrum Disorder (ICD-10: F84.0; F84.3 - F84.9) obtained by an appropriate provider," services "provided directly or billed by the appropriately licensed provider," and "demonstration of functional impairment on a standardized scale of functioning in the past 12 months" such as the VABS-3, ABAS, VB-MAPP… full guide →
Source ↗Iowa Code § 514C.31 requires large-group plans (employers with more than 50 full-time-equivalent employees) and non-state public-employee plans to cover ABA "provided by a practitioner to covered individuals for the treatment of autism spectrum disorder pursuant to a treatment plan"; § 514C.28 does the same for the State of Iowa employee plan. For plans issued or renewed on or… full guide →
Source ↗Iowa licenses behavior analysts under Iowa Code chapter 154D on proof of current BACB (or other accredited) certification; assistant analysts also need ongoing supervision by a licensed behavior analyst, and technicians are exempt paraprofessionals working under a licensed analyst's direction. Iowa is a licensure state, so Aetna's clause that services be "provided directly or… full guide →
Source ↗EN0499 requires a confirmed DSM-5-TR ASD diagnosis "by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice," with "the name, credentials, and type of licensure" of the diagnosing clinician and "the date on which the diagnosis was most recently made." The ABA assessment must be… full guide →
Source ↗Iowa Code § 514C.31 requires large-group plans (employers with more than 50 full-time-equivalent employees) and non-state public-employee plans to cover ABA for autism under a treatment plan; § 514C.28 does the same for the State of Iowa employee plan. For plans issued or renewed on or after January 1, 2026, H.F. 330 removed the age limits and dollar caps and barred annual or… full guide →
Source ↗Iowa licenses behavior analysts under Iowa Code chapter 154D on proof of current BACB (or other accredited) certification; technicians are exempt paraprofessionals working under a licensed analyst's direction. Evernorth does not credential technicians: "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the… full guide →
Source ↗Optum requires "a valid diagnosis of ASD (or other applicable diagnosis as required by governing laws)" from "a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis," with the DSM-5 diagnosis and severity level "confirmed and documented by the diagnosing clinician using at least one clinically validated tool," from… full guide →
Source ↗Iowa Code § 514C.31 requires large-group plans (employers with more than 50 full-time-equivalent employees) and non-state public-employee plans to cover ABA for autism under a treatment plan; § 514C.28 covers the State of Iowa employee plan. For plans issued or renewed on or after January 1, 2026, H.F. 330 removed the age limits and dollar caps and barred annual or lifetime… full guide →
Source ↗Optum's commercial ABA reimbursement policy (2022RP501A, updated June 2026) requires a credential modifier on every line: HM for an RBT, HN for a BCaBA, HO for a master's-level BCBA or licensed mental health provider, HP for a BCBA-D; only one per line. It allows up to 32 units a day of 97153, and 97153/97154 may be billed with 97155 concurrently "as long as the criteria in… full guide →
Source ↗OHCA's ABA provider page states plainly that "the CPT codes 97151, 97153, 97155 and 97156 will be utilized for reimbursement once the provider has a contract with OHCA." There is no 97152 technician-assessment line, no 97154 or 97158 group code, and no 0362T or 0373T. The July 1, 2026 SoonerCare fee schedule prices exactly those four: 97153 at $17.35 per 15-minute unit and… full guide →
Source ↗OAC 317:30-5-313 requires every condition together. The member is under twenty-one with "a definitive diagnosis of an Autism Spectrum Disorder (ASD)" from a pediatric neurologist or neurologist, a developmental pediatrician, a licensed psychologist, a psychiatrist or neuropsychiatrist, another licensed physician experienced in ASD, or an interdisciplinary team of a licensed… full guide →
Source ↗The initial request carries a comprehensive behavioral assessment, an FBA, a BSP if applicable, the treatment plan and OHCA's initial prior-authorization template, plus medical history and prior treatment response, caregiver interviews and rating scales, direct observation data, prior ABA history, a daily schedule by hour with each staff member's credentials, and the other… full guide →
Source ↗OAC 317:30-5-315 is where Oklahoma authorizations are most often lost on process. The "Extension request may only be submitted seven (7) calendar days prior to the end date of the most recent request. Late submissions may result in a technical denial and loss of days." The extension form must be complete, and the packet shows eligibility still met, reduced target-behaviour… full guide →
Source ↗SoonerSelect health plans took over most SoonerCare members on April 1, 2024 across all 77 counties. Members choose among Aetna Better Health of Oklahoma, Humana Healthy Horizons and Oklahoma Complete Health, and OHCA says the plans "cover all services that SoonerCare fee-for-service covers" and "all medically necessary health and behavioral health services, except dental… full guide →
Source ↗Oklahoma licenses behavior analysts. Under 59 O.S. § 1928 as in force through October 31, 2026, a "Licensed behavior analyst" is a BCBA "licensed by the Developmental Disabilities Services Division" of OKDHS, a certified assistant behavior analyst is a BCaBA certified by DDS, "No person shall practice applied behavior analysis without obtaining a license or certification," and… full guide →
Source ↗For an Aetna Better Health member, build the ABA request to OHCA’s rules: a definitive ASD diagnosis from a discipline OAC 317:30-5-313 names and no more than two years old, disruptive behaviour documented within the last 30 days, the intensity tier that decides whether an FBA or BIP is needed, one-to-six-month authorizations, the three-month limit on approved school or… full guide →
Source ↗The plan’s Behavioral Health Prior Authorization Request (OK-23-08-01) has an "APPLIED BEHAVIOR ANALYSIS (ABA)" service type and a dedicated ABA section for initial and concurrent requests, faxed to 833-923-0829 (phone 844-365-4385). The archived manual points to the secure portal and ProPAT for the list of services needing PA. It promised standard decisions within 72 hours… full guide →
Source ↗OK.CP.BH.500 covers ABA requests under "Title 317. Oklahoma Health Care Authority. Part 30" and repeats OHCA’s criteria: a member under 21 with a definitive ASD diagnosis from a named discipline, a comprehensive diagnostic evaluation with medical and social history and DSM criteria or formal test scores (ADI-R, ADOS-2, CARS; "Screening scales are not sufficient"), medical… full guide →
Source ↗Three provider notices changed the claim in 2026. On May 11 the plan reminded providers that "Group ABA therapy is not a covered benefit" and that billing individual ABA codes for group sessions is not permitted, with recoupment on audit. On May 15 it announced it was "increasing required case supervision from 5% to 10% of direct treatment hours," effective June 30, 2026 —… full guide →
Source ↗The manual names the Availity portal as the preferred route for prior authorization, with a fax form (Physical/Behavioral Health fax 1-844-565-0273) for portal downtime; plan phone 833-752-1664, or 833-752-1665 for Children’s Specialty Program members. The manual’s timeframes are "Standard Preservice/Non-Urgent Within 7 calendar days" and 72 hours expedited, in line with state… full guide →
Source ↗Humana’s provider manual lists "Applied behavioral analysis therapy (younger than 21)" as covered and ABA as not covered for adults. Its Oklahoma ABA policy, effective September 16, 2026, adopts OHCA’s Part 30 in full and adds assessment limits: members "may be eligible under the Plan for up to 24 units (6 hours) for an ABA initial assessment," and a reassessment (97151-TS) up… full guide →
Source ↗The June 18, 2026 notice moved reassessment billing to 97151 with modifier TS from September 16, 2026 ("Providers should continue submitting prior authorization requests as they do today"). The July 14, 2026 notice raises required case supervision from 5% to 10% of direct treatment hours effective October 12, 2026, and encourages providers to adopt it earlier. Requests go… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder and considers it experimental for Down syndrome without ASD and for every other non-ASD indication (CPB 0554). The working criteria are in the ABA medical necessity guide: a DSM-5 ASD diagnosis from an appropriate provider, services "provided directly or billed by the appropriately licensed provider," functional impairment on a… full guide →
Source ↗36 O.S. § 6060.21 requires "a health benefit plan and the Oklahoma Employees Health Insurance Plan" to cover "the screening, diagnosis and treatment of autism spectrum disorder in individuals." Since SB 1240 took effect on November 1, 2022, the statute has no age window and no ABA cap: coverage "shall not be subject to any limits on the number of visits," and dollar limits,… full guide →
Source ↗Oklahoma requires a state license to practise ABA. Under 59 O.S. § 1928, "No person shall practice applied behavior analysis without obtaining a license or certification," supervisees practise only under a licensed behavior analyst, and licensed human services professionals (psychologists, LPCs, LCSWs, OTs, SLPs and others) may practise ABA within their scope. Through October… full guide →
Source ↗EN0499 covers ABA for a confirmed DSM-5-TR autism diagnosis and treats it as not medically necessary for every non-ASD indication, Rett syndrome included. The assessment must be done by a BCBA, a licensed behavior analyst or an independently licensed clinician trained in ABA, using a complete, current-edition standardized instrument. Case supervision is expected at "one to two… full guide →
Source ↗36 O.S. § 6060.21 requires "a health benefit plan and the Oklahoma Employees Health Insurance Plan" to cover "the screening, diagnosis and treatment of autism spectrum disorder in individuals." Since SB 1240 took effect on November 1, 2022, the statute has no age window and no ABA cap: coverage "shall not be subject to any limits on the number of visits," and dollar limits,… full guide →
Source ↗Oklahoma requires a state license to practise ABA. Under 59 O.S. § 1928, "No person shall practice applied behavior analysis without obtaining a license or certification," supervisees practise only under a licensed behavior analyst, and licensed human services professionals (psychologists, LPCs, LCSWs, OTs, SLPs and others) may practise ABA within their scope. Through October… full guide →
Source ↗Optum requires a DSM-5-TR ASD diagnosis from "a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis," confirmed with at least one clinically validated tool (screeners such as the M-CHAT or CARS-2 up to formal instruments such as the ADI-R and ADOS-2). Prior authorization applies to all ABA, with assessment and treatment… full guide →
Source ↗36 O.S. § 6060.21 requires "a health benefit plan and the Oklahoma Employees Health Insurance Plan" to cover "the screening, diagnosis and treatment of autism spectrum disorder in individuals." Since SB 1240 took effect on November 1, 2022, the statute has no age window and no ABA cap: coverage "shall not be subject to any limits on the number of visits," and dollar limits,… full guide →
Source ↗Oklahoma requires a state license to practise ABA. Under 59 O.S. § 1928, "No person shall practice applied behavior analysis without obtaining a license or certification," supervisees practise only under a licensed behavior analyst, and licensed human services professionals (psychologists, LPCs, LCSWs, OTs, SLPs and others) may practise ABA within their scope. Through October… full guide →
Source ↗BCBSOK’s 2026 commercial behavioral health PA code list names 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T, each "Managed By BCBSOK", for Blue Choice PPO, Blue Choice Preferred PPO and Blue Traditional; 97151 and 97152 are not on it. Its Initial Assessment Request form still exists ("Submit form at least two weeks before requested start date") and says that if it… full guide →
Source ↗CPCP011 (plan effective March 20, 2026) is unusually specific. Direct services are "typically requested for up to 40 hours per week"; an assessment over "eight hours (32 units of 97151)" may not be paid; parent education is typically authorized at an hour a week for a 26-week period; and daily units follow the CMS MUE table and the authorization. Only one BCBA may bill the… full guide →
Source ↗36 O.S. § 6060.21 requires "a health benefit plan and the Oklahoma Employees Health Insurance Plan" to cover "the screening, diagnosis and treatment of autism spectrum disorder in individuals." Since SB 1240 took effect on November 1, 2022, the statute has no age window and no ABA cap: coverage "shall not be subject to any limits on the number of visits," and dollar limits,… full guide →
Source ↗Oklahoma requires a state license to practise ABA. Under 59 O.S. § 1928, "No person shall practice applied behavior analysis without obtaining a license or certification," supervisees practise only under a licensed behavior analyst, and licensed human services professionals (psychologists, LPCs, LCSWs, OTs, SLPs and others) may practise ABA within their scope. Through October… full guide →
Source ↗Michigan splits Medicaid behavioral health in two. Mild-to-moderate outpatient mental health belongs to the Medicaid Health Plans (MHPs) and fee-for-service; specialty behavioral health, including autism, belongs to the PIHPs. The Medicaid Provider Manual is explicit for autism: once the primary care provider screens a child and decides a referral is necessary, "the PIHP is… full guide →
Source ↗The manual lays out a fixed order. Screening happens at an EPSDT well-child visit with a validated, standardized tool, and "A full medical and physical examination must be performed before the child is referred for further evaluation." The PCP then refers the child to the PIHP for the county, and the PIHP contacts the family to schedule a comprehensive diagnostic evaluation… full guide →
Source ↗BHT must be delivered under the direction of a BCBA/LBA, who is responsible for the behavioral plan of care, for supervising BCaBAs and technicians, and for reporting progress on goals to parents every three to six months. Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (licensure law enacted 2016): the… full guide →
Source ↗ABA is billed to the PIHP or CMHSP under your network contract, not to CHAMPS fee-for-service. MDHHS’s SFY 2026 Behavioral Health Code Charts set the reporting rules every PIHP uses: all ABA codes are per 15 minutes; staff-level modifiers identify the rendering provider (HO licensed behavior analyst, HN licensed assistant behavior analyst, HM behavior technician); 97151… full guide →
Source ↗MDHHS ran a competitive procurement for the PIHP contracts, with an RFP issued in August 2025 (bids due September 29, 2025) and a stated goal of a service start date of October 1, 2026. The RFP was limited to nonprofit organizations with additional consideration for public entities, and the PIHP "must contract with CMHSPs to provide a comprehensive array of mental health… full guide →
Source ↗DWIHN runs a "no wrong door" model: a parent, a physician, a therapist or a teacher can refer to the Access Call Center at 1-800-241-4949. On the call, Access checks the child’s insurance, completes a CMH screening and an autism screening tool. If the screening shows elevated signs of autism, "An evaluation appointment will be scheduled with one of our independent evaluation… full guide →
Source ↗DWIHN’s ASD benefit document rules (revised 6/20/20) set the paperwork rhythm providers upload to the MH-WIN record: the ABA assessment and plan with ABLLS, VB-MAPP or AFLS grids every 180 days; the IPOS every 365 days; monthly supports-coordinator and BCBA/QBHP contact notes; quarterly IPOS service reviews; the comprehensive diagnosis evaluation and form within 7 days… full guide →
Source ↗DWIHN’s Utilization Management department publishes its 2025 performance: a 99% standard prior-authorization approval rate, 0% timeframe extensions, standard authorizations averaging 3.2 days (median 0 days) and expedited authorizations averaging 16.5 hours; 32.6% of appealed standard denials were approved on appeal. Claims are processed for four lines of business including a… full guide →
Source ↗OCHN publishes its sequence. Children not already receiving CMH services are screened through OCHN Access (248-464-6363); children already in CMH services are screened for ABA by their core provider agency. "A full medical and physical examination is required prior to a referral to OCHN." The diagnostic evaluation is "Performed by OCHN clinical diagnostician" and combines a… full guide →
Source ↗Families pick both an ABA provider (for therapy) and a CPA (for support coordination). OCHN’s provider info sheet asks families to name two or three preferred ABA agencies and lists each agency’s setting (center, in-home, telehealth), hours and ages served; many serve 18 months to 21 years. OCHN describes each ABA plan as averaging "five to twenty-five hours of direct… full guide →
Source ↗Families call MCCMH Customer Service at 855-99-MCCMH (855-996-2264); MCCMH registers the child, checks Medicaid, and a clinician does a phone screening, then schedules an intake with one of three autism case management programs (Easterseals MORC, Specialized Children & Family Services, Hope Network). "A child can access the ASD benefit only if they qualify for Medicaid." At… full guide →
Source ↗The behavioral assessment (VB-MAPP, ABLLS-R or AFLS) is completed before ABA starts and then at least every six months, and it sets the service level: focused (average 5–15 hours a week) or comprehensive (16–25). MCCMH’s worked example: an initial assessment on 2/10/26 opens a six-month window through 8/9/26; the case manager updates the IPOS and requests authorization "14 or… full guide →
Source ↗MSHN’s CMHSP participants are Bay-Arenac, CMH for Central Michigan (Clare, Gladwin, Isabella, Mecosta, Midland, Osceola), Clinton-Eaton-Ingham, Gratiot, Huron, The Right Door for Hope (Ionia), LifeWays (Jackson, Hillsdale), Montcalm Care Network, Newaygo, Saginaw, Shiawassee Health & Wellness, and Tuscola. MSHN’s procedure (reviewed March 3, 2026) follows the manual’s sequence… full guide →
Source ↗For a child evaluated outside the CMH system, MSHN tells its CMHSPs to accept the comprehensive diagnostic evaluation when it "was completed within the last three years and prior to beginning BHT services," covers cognitive, behavioral, emotional, adaptive and social functioning with validated tools, general treatment recommendations and a referral for an ABA behavioral… full guide →
Source ↗MSHN’s Utilization Management procedure (reviewed May 7, 2024) requires that a decision denying or limiting services be noticed "within 14-days following receipt of the request for service for standard authorization decisions, or within 72-hours" for expedited ones; a decision not reached in time is itself a denial requiring an adverse benefit determination notice, and the… full guide →
Source ↗Step 1 is screening, by the child’s primary care physician or the local CMHSP access center, with the M-CHAT or the Social Communication Questionnaire. Step 2 is the diagnostic evaluation, which "takes approximately 3 hours and is completed during two appointments" using the ADOS-2, ADI-R and DD-CGAS; "Once completed, the results are sent to the Michigan Department of Health… full guide →
Source ↗SWMBH lists the county access lines: Integrated Services of Kalamazoo 269-373-6000; Woodlands (Cass) 269-445-2451; Summit Pointe (Calhoun) 269-966-1460; Van Buren Community Mental Health 269-657-5574; Riverwood (Berrien) 269-925-0585; Pines Behavioral Health (Branch) 517-278-2129; St. Joseph County Community Mental Health 269-467-1000; Barry County Community Mental Health… full guide →
Source ↗Before an ABA provider can ask Blue Cross Behavioral Health for prior authorization, the member needs a comprehensive diagnostic evaluation showing the DSM criteria for autism, completed by a licensed physician, licensed psychologist or other licensed clinician qualified to diagnose autism. Michigan members have two routes: an approved autism evaluation center (AAEC), which… full guide →
Source ↗Blue Cross Behavioral Health manages autism prior authorizations for Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage. The procedure-code list (v.2026.3) marks 97151 through 97158 as requiring prior authorization for BCN HMO, Medicare Plus Blue PPO, and Blue Cross commercial "fully insured groups and … select self-funded groups," and the member page… full guide →
Source ↗Blue Cross’s July 2026 documentation standards spell out each note: patient identification, place of service and any telemedicine, technician and supervising LBA with credentials, date with start and stop times (narratives in no more than four-hour blocks), interventions, data and progress, and the signatures and credentials of the RBT and supervising LBA (97153/97154) or the… full guide →
Source ↗Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum… full guide →
Source ↗Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior… full guide →
Source ↗Initial diagnostic evaluation, including psychological testing, is medically necessary, and the diagnosis must match the DSM standard at the time of evaluation. The evaluation must show a multimodal assessment (caregiver reports, records, collateral reports, standardized psychological tools and an observational assessment), and Priority Health "may require a second diagnostic… full guide →
Source ↗Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum… full guide →
Source ↗Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior… full guide →
Source ↗HAP’s Prior Authorization List Summary (reviewed July 10, 2026) lists "Applied Behavioral Analysis (ABA) Treatment" among services requiring prior authorization and refers providers to the "Coordinator Behavioral Health Management-Outpatient Authorization list for detailed information," which, like HAP’s InterQual criteria, requires a provider login. HAP’s Coordinated… full guide →
Source ↗Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum… full guide →
Source ↗Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under CPB 0554 (with CPB 0648 for ASD) and its ABA medical necessity guide, which requires a DSM-5 ASD diagnosis from an appropriate provider, functional impairment on a standardized scale within the past 12 months, a measurable treatment plan with transition and discharge criteria, parent engagement, and services delivered or… full guide →
Source ↗Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum… full guide →
Source ↗Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior… full guide →
Source ↗EN0499 (effective May 15, 2026) covers ABA for a confirmed ASD diagnosis (F84.0–F84.9, excluding F84.2 Rett syndrome) made by an independently licensed clinician, with the diagnosing clinician’s name, credentials and the date of the most recent diagnosis. The ABA assessment must use a current, standardized instrument covering the DSM-5-TR domains, and baseline data must be… full guide →
Source ↗Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum… full guide →
Source ↗Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior… full guide →
Source ↗Optum’s ABA Supplemental Clinical Criteria (annual review August 2025, interim review April 2026) require prior authorization for ABA "unless otherwise specified or mandated by contract or law," a valid DSM-5-TR ASD diagnosis from a state-licensed physician, psychologist or other qualified clinician confirmed with at least one validated tool, a credentialed provider (BCBA or… full guide →
Source ↗Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum… full guide →
Source ↗Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior… full guide →
Source ↗Med-QUEST issues ABA guidance to the QI plans and to fee-for-service through paired provider memos. The current pair is QI-2431 and FFS 24-13, dated December 31, 2024, titled "Coverage of Intensive Behavioral Therapy (IBT) for Treatment of Children Under 21 Years of Age with Autism Spectrum Disorder (ASD): Guidelines for Applied Behavioral Analysis (ABA)." It restates the… full guide →
Source ↗Screening happens at the PCP’s EPSDT visits and needs no PA. The diagnosis "shall be made by" a developmental behavioral pediatrician, developmental pediatrician, neurologist, pediatrician, psychiatrist, psychologist, or another licensed practitioner with specialized expertise in ASD, using "evidence-based assessments." The diagnostic evaluation needs no PA, "but QI health… full guide →
Source ↗Med-QUEST sets the benefit; each QI plan runs its own authorization "established (MQD reviewed and approved) policy for PA," so the plan name is a required intake field. What the plans publish differs. AlohaCare issued its own ABA medical policy, MP-37, effective March 22, 2026, and its PA lookup requires authorization for every ABA code including 97151. ʻOhana’s PA list… full guide →
Source ↗Attachment C (revised 12/2024) publishes the FFS ABA rates "as of 2025," per 15 minutes: 97151 (LBA, HO) $28.52; 97152 (BCaBA, HN) $20.24; 0362T (LBA) $54.71; 97153 $17.66 (the HM RBT rate; Med-QUEST’s December 2024 FAQ lets LBAs and BCaBAs bill 97153 at that rate); 97155 LBA $35.94 and BCaBA $20.24; 97156 LBA $46.20 and BCaBA $25.01; group codes 97154, 97157 and 97158 paid… full guide →
Source ↗MP-37 covers ABA under EPSDT for members under 21 when all its criteria are met. Eligibility needs a DSM-5 ASD diagnosis "including documentation of early developmental symptoms AND standardized diagnostic evaluation tools (i.e., ADOS-2, CARS-2, ADI-R)," made by a developmental-behavioral pediatrician, developmental pediatrician, pediatrician, neurologist, psychologist or… full guide →
Source ↗AlohaCare’s PA lookup, which the plan calls the most current source, lists 97151 through 97158, 0362T and 0373T as prior-authorization codes for QUEST, effective since 2018–2019 and confirmed on September 23, 2026. The diagnostic evaluation (for example 90791) needs no authorization. Requests go on the Request for Authorization and Notification form. AlohaCare reviews against… full guide →
Source ↗An HMSA QUEST member gets the Med-QUEST ABA benefit administered by HMSA: under 21, ASD diagnosis per the memo, treatment prior-authorized in hours per week for up to 26 weeks, supervision at 1–2 hours per 10 RBT hours, Medicaid secondary to other coverage. HMSA added "Applied Behavior Analysis Therapy for Treatment of Autism Spectrum Disorder" to its QUEST precertification… full guide →
Source ↗Hawaii’s autism mandate is Luke’s Law, Act 235 of 2015. It added the same autism section three times — to the insurance code as HRS § 431:10A-133, to chapter 432 for mutual benefit societies (HMSA’s chapter), and, through HRS § 432D-23, to HMO contracts — so every state-regulated carrier in Hawaii carries it. The text is narrow by current standards. Policies issued or renewed… full guide →
Source ↗Hawaii licenses behavior analysts under HRS chapter 465D, run by the Department of Commerce and Consumer Affairs. A license requires having passed the BCBA examination and maintaining active BACB status as a BCBA or BCBA-D (HRS § 465D-8). Section 465D-7 exempts, among others, BCaBAs practicing "under the direction of a licensed behavior analyst," RBTs who directly implement… full guide →
Source ↗Not yet read: HMSA’s ABA medical policy and its code-level prior-authorization list — both now at hmsa.policytransparency.com, which asks users to accept HMSA’s medical policy terms of use before it shows content, so we did not open them. So the following are unknown here: whether 97151 itself is precertified, HMSA’s clinical criteria and diagnostic-tool requirements, hour… full guide →
Source ↗ʻOhana’s FAQ (approved August 14, 2026): members were to be notified in early September; the special open enrollment runs October 1–20, 2026; members who don’t choose are assigned; enrollment and transition-of-care files move to the new plans from mid-November; new coverage starts January 1, 2027. Providers should keep treating ʻOhana members through December 31, 2026. On… full guide →
Source ↗ʻOhana’s CMS-0057-F prior-authorization list (effective 12/31/2025) names ABA Services 97151 through 97158, and separately lists neuropsychological and psychological testing (96112–96146). The fastest route is the WellCare provider portal; fax is also accepted, and phone only for urgent requests, which are decided within 72 hours. ʻOhana’s published 2025 QUEST metrics show… full guide →
Source ↗Both network and out-of-network providers manage ABA in the Provider Express secure portal (a One Healthcare ID is required): verify coverage, request ABA assessment and treatment authorizations, send more information, and track status. Optum’s Hawaii orientation sets eligibility as under 21, covered by QUEST Integration, with a documented DSM-5 ASD diagnosis. It allows a… full guide →
Source ↗Kaiser’s QUEST manual: when services from an outside provider are needed, "an authorization request is submitted and processed through Kaiser Permanente’s Authorization and Referral Management Department (ARM)," and the Kaiser Physician-in-Charge makes the final review of out-of-plan requests, "including Behavioral Health." Referrals are authorized "for specific services,… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under CPB 0554 (with CPB 0648 for ASD) and its ABA medical necessity guide, and considers ABA "experimental, investigational, or unproven" for Down syndrome without ASD and for all other non-ASD indications. The guide requires a DSM-5 ASD diagnosis by an appropriate provider, functional impairment on a standardized scale within the… full guide →
Source ↗Hawaii’s autism mandate is Luke’s Law, Act 235 of 2015. It added the same autism section three times — to the insurance code as HRS § 431:10A-133, to chapter 432 for mutual benefit societies (HMSA’s chapter), and, through HRS § 432D-23, to HMO contracts — so every state-regulated carrier in Hawaii carries it. The text is narrow by current standards. Policies issued or renewed… full guide →
Source ↗Hawaii licenses behavior analysts under HRS chapter 465D, run by the Department of Commerce and Consumer Affairs. A license requires having passed the BCBA examination and maintaining active BACB status as a BCBA or BCBA-D (HRS § 465D-8). Section 465D-7 exempts, among others, BCaBAs practicing "under the direction of a licensed behavior analyst," RBTs who directly implement… full guide →
Source ↗Aetna does not publish commercial ABA fee schedules for Hawaii; rates are set in your participating-provider agreement. Med-QUEST’s published FFS ABA rates (97153 at $17.66 per 15 minutes for 2025) are a public reference point, not a commercial floor.
Source ↗EN0499 covers an ABA assessment and treatment for a confirmed ASD diagnosis (F84.0–F84.9, except F84.2 Rett syndrome) made under DSM-5-TR by a professional licensed to practice independently with diagnosis in scope. It requires the diagnoser’s name, credentials and licensure and "the date on which the diagnosis was most recently made." The assessment must be done by a BCBA,… full guide →
Source ↗Hawaii’s autism mandate is Luke’s Law, Act 235 of 2015. It added the same autism section three times — to the insurance code as HRS § 431:10A-133, to chapter 432 for mutual benefit societies (HMSA’s chapter), and, through HRS § 432D-23, to HMO contracts — so every state-regulated carrier in Hawaii carries it. The text is narrow by current standards. Policies issued or renewed… full guide →
Source ↗Hawaii licenses behavior analysts under HRS chapter 465D, run by the Department of Commerce and Consumer Affairs. A license requires having passed the BCBA examination and maintaining active BACB status as a BCBA or BCBA-D (HRS § 465D-8). Section 465D-7 exempts, among others, BCaBAs practicing "under the direction of a licensed behavior analyst," RBTs who directly implement… full guide →
Source ↗Optum’s ABA criteria require a valid ASD diagnosis "issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis" under DSM-5-TR, with diagnosis and severity confirmed by at least one clinically validated tool (screening tools such as M-CHAT, second-level tools such as CARS-2, or formal tools such as ADI-R and ADOS-2).… full guide →
Source ↗Hawaii’s autism mandate is Luke’s Law, Act 235 of 2015. It added the same autism section three times — to the insurance code as HRS § 431:10A-133, to chapter 432 for mutual benefit societies (HMSA’s chapter), and, through HRS § 432D-23, to HMO contracts — so every state-regulated carrier in Hawaii carries it. The text is narrow by current standards. Policies issued or renewed… full guide →
Source ↗Hawaii licenses behavior analysts under HRS chapter 465D, run by the Department of Commerce and Consumer Affairs. A license requires having passed the BCBA examination and maintaining active BACB status as a BCBA or BCBA-D (HRS § 465D-8). Section 465D-7 exempts, among others, BCaBAs practicing "under the direction of a licensed behavior analyst," RBTs who directly implement… full guide →
Source ↗The State Plan (Limitations on Attachment 3.1-A, effective January 1, 2025) covers BHT "as medically necessary services for Medi-Cal members under 21 years of age, regardless of diagnosis, based upon a recommendation of a licensed physician or a licensed psychologist." APL 23-010 frames it the same way: coverage "includes children diagnosed with autism spectrum disorder (ASD)… full guide →
Source ↗Managed-care members (about 12.8 million people across all Medi-Cal medical plans in August 2026): BHT is the plan's responsibility. APL 23-010 says "MCPs have primary responsibility for ensuring that EPSDT members receive all Medically Necessary BHT services," and "When services provided by a LEA or RC do not fulfill all of the Member's medical need for BHT services, the MCP… full guide →
Source ↗Every California county runs one of five plan models: County Organized Health System (one public plan for the county — 34 counties, e.g. CalOptima in Orange and Partnership HealthPlan across the north), Two-Plan (a local initiative plus a commercial plan — 14 counties, e.g. L.A. Care and Health Net in Los Angeles), Geographic Managed Care (Sacramento and San Diego, several… full guide →
Source ↗California has no behavior analyst license — it does not appear on the BACB's licensure table. In Medi-Cal, staffing runs on the qualified autism service (QAS) tiers in State Plan Supplement 6 (effective January 1, 2026). A QAS Provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board, that is accredited by the National Commission… full guide →
Source ↗Medi-Cal does not price fee-for-service BHT on a DHCS CPT-unit schedule for behavior analysts. State Plan Attachment 4.19-B (pp. 89–90, effective January 1, 2025) pays behavior analysts, associate behavior analysts, behavior management assistants and behavioral technicians their "usual and customary rate" if they have one, and otherwise "the Department of Developmental… full guide →
Source ↗A PCP or family starts it: PCPs call 888-347-2264 or email ASDBenefit@lacare.org, or ask the "patient, parent, or caregiver to contact L.A. Care BHT team directly." The authorization form LA5480 (May 2026) says "All 4 criteria must be met for approval" — the member is under 21, has a licensed physician/surgeon/psychologist recommendation "with documentation demonstrating… full guide →
Source ↗CA.CP.BH.104 applies APL 23-010 with Health Net’s own clocks. The recommendation comes from "A licensed physician or licensed clinical psychologist … regardless of diagnosis" (Health Net’s referral form is "encouraged"); where there is no diagnosis or a non-autism diagnosis, "the recommendation/referral form must be less than one year old." Initiation needs a behavioral… full guide →
Source ↗IEHP’s evaluation criteria (UM_BH 08) need an ASD diagnosis, suspected ASD, or a determination that BHT is medically necessary; medical stability; and "a formal request from a physician or psychologist requesting BHT Services that outlines the member excesses and/or deficits of behaviors that significantly interfere with home or community activities." Everything is authorized:… full guide →
Source ↗GG.1548 spells it out. The recommendation must carry the full name and credentials of a licensed physician, surgeon or licensed clinical psychologist — it "cannot be an educational psychologist or master’s level clinician/practitioner (LMFT, LCSW, LPCC, PA, NP, etc.)," though an NP or PA recommendation works with an MD signature. The recommendation and diagnosis must come… full guide →
Source ↗Anthem’s Medi-Cal manual says "requests for precertification for ABA should be submitted via fax to 855-473-7902," and the May 2026 Treatment Plan Request Form names Availity Essentials "our preferred method," with the fax as fallback. The same form handles "initial assessment requests when requesting only 97151/97152 and 0362T" — attach a diagnostic evaluation, Anthem’s… full guide →
Source ↗No ABA-specific clinical guideline is named for Medi-Cal — Anthem’s UM policy lists Anthem medical and clinical guidelines, MCG (licensed) and Carelon guidelines as its criteria families, available "upon request." Its California behavioral health reimbursement policy page reads "Coming soon," so there is no published rule on concurrent billing or unit edits. Contact details… full guide →
Source ↗Molina’s ABA program page and referral form send new families through Molina itself: an MD or licensed clinical psychologist "who has seen the member within the last 12 months" completes the ABA Referral Form (with "most recent clinicals (within 1 year)"), and it goes to PedsCA@molinahealthcare.com or fax (855) 297-3010. "A Molina Case Manager will contact the family … and… full guide →
Source ↗Clinical Policy No. 482 (last approved June 10, 2026) is Molina’s national ABA policy, and several of its criteria are stricter than DHCS APL 23-010: it requires "a valid diagnosis of Autism Spectrum Disorder (ASD)" made by a multidisciplinary team "utilizing at least ONE clinically validated tool"; sets "ASD initiation age is 18 months or older"; wants updated documentation… full guide →
Source ↗The 2026 Medi-Cal member handbook covers BHT "for members under 21 years old through the Medi-Cal for Kids and Teens benefit," when it is "prescribed by a licensed doctor or psychologist, approved by us, and provided in a way that follows the approved treatment plan." Outside providers need "a referral or pre-approval." Kaiser’s Northern California provider manual explains the… full guide →
Source ↗Kaiser Southern California’s Medi-Cal BHT criteria cover BHT "for members with an ASD diagnosis, or where following formal assessment there is suspicion of ASD that is not yet diagnosed," and separately for members without an ASD diagnosis — consistent with the state’s "regardless of diagnosis" rule. But for the non-ASD path the service must be "Provided by a licensed provider… full guide →
Source ↗Policy MCUP3126 (reviewed April 8, 2026) requires a TAR for all BHT. The TAR must include the "Medical or mental health diagnosis," the "Length and severity of the condition," a history and physical "including mental status, development status and/or any form of comprehensive diagnostic testing," and "The Functional Behavioral assessment conducted by a Board Certified Behavior… full guide →
Source ↗Partnership states it "is the primary Provider of medically necessary BHT services" and must fill gaps the school district leaves; it "must not assume that BHT services included in a Member’s IEP/IHSP/IFSP are actively being provided by the LEA." A child moving from a Regional Center automatically generates a continuity-of-care request, and continuity with an out-of-network… full guide →
Source ↗The 2026 EOC puts BHT among the few mental health services that need a referral: "a Plan Physician must refer you before you can get Behavioral Health Treatment for Autism Spectrum Disorder." Kaiser’s Northern California physician site walks through the path: "Your child’s doctor will send a referral to the PDCP for a BHT evaluation"; a partner agency — the primary partner is… full guide →
Source ↗California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO, including Kaiser Foundation Health Plan, and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402… full guide →
Source ↗California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional… full guide →
Source ↗Blue Shield’s October 2025 provider webinar announced it "will begin directly managing Behavioral Health services members enrolled in commercial HMO and PPO plans … including Applied Behavioral Analysis (ABA)," replacing its mental health service administrator, Human Affairs International of California (Magellan); requests for dates of service from January 1, 2026 "must be… full guide →
Source ↗California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every… full guide →
Source ↗California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional… full guide →
Source ↗Anthem’s California PPO precertification list (updated August 24, 2026, effective September 1, 2026) lists every ABA code — 97151–97158, 0362T, 0373T, H0031, H0032, H0046, H2012, H2014 and H2019 — with Anthem as the responsible party and "Contact Behavioral Health at the number on the member’s ID card." Its criteria column reads "American Academy of Child and Adolescent… full guide →
Source ↗California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every… full guide →
Source ↗California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional… full guide →
Source ↗Health Net now administers behavioral health itself — "Health Net manages inpatient and outpatient treatment for behavioral health" — and ABA requests go to the "Health Net Behavioral Health Autism Center" at ABA@healthnet.com or fax 855-427-4798 (BH provider services 844-966-0298). The front door is the Confirmation of Diagnosis form, completed by a physician or licensed… full guide →
Source ↗California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every… full guide →
Source ↗California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional… full guide →
Source ↗Aetna covers ABA for autism spectrum disorder under CPB 0554 (with CPB 0648 for ASD) and its ABA medical necessity guide, and considers ABA experimental for other indications. Nationally, the behavioral health precertification list names all ten ABA codes (97151–97158, 0362T, 0373T), and form GR-69017-4 — the 7-26 version, which "Effective August 1, 2026 … replaces all other"… full guide →
Source ↗California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every… full guide →
Source ↗California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional… full guide →
Source ↗Evernorth bases ABA decisions "on the Intensive Behavioral Interventions - (EN0499) coverage policy unless contractual requirements or federal or state law requires the use of other specifically identified clinical criteria." EN0499 (effective May 15, 2026) names no California exception. In-network assessments (97151, 97152, 0362T) need no prior authorization; treatment does.… full guide →
Source ↗California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every… full guide →
Source ↗California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional… full guide →
Source ↗Provider Express’s "State-Specific Clinical Criteria" — criteria "used to make medical necessity determinations … when there are explicit mandates or contractual requirements outside of the Criteria above" — list "California Commercial – Applied Behavior Analysis: The Council of Autism Service Providers (CASP) Applied Behavior Analysis Practice Guidelines for the Treatment of… full guide →
Source ↗California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every… full guide →
Source ↗California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional… full guide →
Source ↗Chapter 1155 pays for IBHS "when the services are medically necessary and provided to eligible children, youth or young adults with a behavioral health diagnosis by licensed IBHS agencies" — a child is under 14, a youth 14 to under 18, a young adult 18 to under 21. ABA services are one of four IBHS families, delivered through four service types: behavior analytic services,… full guide →
Source ↗Everything hangs on the written order in 55 Pa. Code § 1155.33(a)(1). It must be based on a face-to-face interaction with the child, written within 12 months before ABA starts, by "a licensed physician, licensed psychologist, certified registered nurse practitioner or other licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health… full guide →
Source ↗In HealthChoices, "Each HealthChoices consumer is assigned a Behavioral Health Managed Care Organization (BH-MCO) based on his or her county of residence." DHS's current map: Community Behavioral Health (CBH) serves Philadelphia; Community Care Behavioral Health serves 41 counties including Allegheny, Berks, Chester, Delaware, Erie, Lackawanna, Luzerne and York; Magellan… full guide →
Source ↗Pennsylvania's autism insurance law (Act 62 of 2008) named the Medical Assistance program as a "government program" and pushed private insurers to pay first. DHS's Act 62 page states the operating rule: providers must "bill a child's or adolescent's private health insurance company before submitting a claim for the diagnostic assessment or treatment of ASD," and the IBHS rule… full guide →
Source ↗OMHSAS's IBHS code table (OMHSAS-21-03, Attachment A, January 2021) lists the MA fee-for-service ABA rates per 15-minute unit: 97151 behavior identification assessment $22.09 (BC-ABA) or $24.73 with the U7 modifier (behavior analytic / BC-ABA by a BCBA); 97152 $12.73 (BHT-ABA) or $15.76 (U8, Asst. BC-ABA); 97153 $12.73 (BHT-ABA) or $15.76 (U8); 97155 and 97156 $22.09 or $24.73… full guide →
Source ↗Community Care’s provider manual sends providers to its “Guidelines for Obtaining Approval” (Appendix A) to see whether a service needs registration, notification or prior authorization. The July 2026 grid lists “IBHS — Written Order: 60 Days from Service Start, ePortal, Registration” and “IBHS — Assessment: 30 Days from Service Start, ePortal, Registration”; IBHS treatment is… full guide →
Source ↗Community Care’s IBHS Performance Standards make a face-to-face evaluation by a licensed prescriber the first step, and list ways to get one: a PCP or CRNP wellness check, an outpatient intake or therapy session, a psychological or psychiatric evaluation, testing, a discharge from inpatient/RTF/partial, or a mental health assessment by a PROMISe-enrolled prescriber at an IBHS… full guide →
Source ↗Community Care issued its own medical necessity guidelines for ABA one-to-one center-based services (effective 7/8/2026; providers had to comply by July 10, 2026 per Provider Alert 10). Children appropriate for center-based ABA “are typically under the age of 6 years old, and present with documented neurodevelopmental delays”, and the written order must recommend center-based… full guide →
Source ↗Community Care’s Act 62 page tells providers they “are required to bill private health insurance for the costs associated with ASD for children under the age of 21”, to “verify eligibility, benefits, and cap amount each time an ASD member presents”, and to include the commercial plan’s explanation of payment “with each ASD claim” (plus an exhaustion letter once a cap is… full guide →
Source ↗CBH’s member handbook lists “IBHS Applied Behavior Analysis (ABA) Services — Prior Authorization Required: Yes”, and the provider manual’s authorization grid says: “For ABA-Initial Assessment and ABA-Initial Treatment, only WO is required. All concurrent requests require WO, IBHS Assessment including FBA and/or Skills Assessment, and Individual Treatment Plan (ITP).” There is… full guide →
Source ↗Bulletin 25-25 (July 31, 2025) and the September 2025 FAQ changed how CBH reviews ABA. For requests reviewed from September 1, 2025, “CBH will not authorize IBHS services unless the ITP includes at least two parent/caregiver training goals and minimal monthly parent/caregiver training sessions” (weekly is best practice). CBH does a medical-necessity review for every youth with… full guide →
Source ↗CBH bills ABA by level-of-care code on each provider’s Schedule A: 425-6 Assessment-ABA, 425-7 Initial Treatment-ABA, 425-28 BCBA, 425-29 Behavior Consultation, 425-30 Assistant Behavior Consultation and 425-31 BHT-ABA. Each maps to CPT 97151–97156, and pricing modifiers show the credential: U7 for Behavior Analytic, U8 for Assistant BC-ABA, none for BC-ABA and BHT-ABA. Two… full guide →
Source ↗CBH contracts ABA Early Childhood programs for children “ages 3-5 who have not yet entered kindergarten” who cannot be served in a less restrictive setting. Children need a primary ASD diagnosis “with Level 2 or 3 severity for either the social communication or restricted, repetitive behaviors and interests domains”. Programs run at least 240 days a year with at least four… full guide →
Source ↗Magellan’s handbook supplement describes IBHS as three categories — individual services, ABA, and group services — delivered in home, school and community. Everything starts with a written order (WO) based on a face-to-face interaction: it must name a behavioral health diagnosis, the IBHS service, hours and settings, the clinical information supporting medical necessity, and… full guide →
Source ↗Initial assessment registration Submit the IBHS Registration TAR cover sheet and the written order through Availity. Magellan authorizes 24 hours (96 units) over 45 calendar days for an ABA assessment (97151 HA); regulation still expects it completed within 30 calendar days. Providers have 7 calendar days to schedule the first assessment appointment after receiving a verified… full guide →
Source ↗The supplement’s table: pre-service urgent up to 3 hours, pre-service standard 2 business days, concurrent review 1 business day, retro review 30 calendar days. If information is missing Magellan requests it within 48 hours, the provider has up to 14 calendar days to answer, and the decision follows within 2 business days (initial) or 1 business day (concurrent) of receipt.… full guide →
Source ↗Magellan’s supplement: "Medicaid is always the last payer"; claims go to the primary insurer first for an EOB, and "HealthChoices will not make payments if the full obligations of the primary insurer are not met." When the service is covered by the other insurance, the member must use a provider in both networks. Magellan’s training adds that it "cannot reimburse as primary… full guide →
Source ↗Magellan pays IBHS under provider contracts and fee schedules that are not published. Its July 2026 workgroup notes recent rate increases and asks providers to bill usual-and-customary charges so claims can be swept up to new rates, and describes a 2026 access-based incentive model (at least 25 individual or ABA initial assessments a year; members with commercial insurance are… full guide →
Source ↗1. Written order or BPE From an ORP-enrolled prescriber (clinic prescribers must include the clinic or medical director MA number). A Best Practice Evaluation can stand in if it meets every written-order requirement. The order is valid 12 months minus one day from the face-to-face. 2. Provider choice The IBHS Individual/ABA Provider Choice Acknowledgment Form is completed with… full guide →
Source ↗IBHS 22-102 lays out the bundles: a 97151 registration (no MNC decision) also lets ABA agencies bill 97152/97152 U8; an authorization for 97155 (medical-necessity review) covers 97156/97156 U7; and PerformCare requires separate authorization for 97155 U7 (behavior analyst) and 97153 U8 (assistant behavior consultation-ABA). IBHS 21-105 confirms a BCBA working as BC-ABA bills… full guide →
Source ↗PerformCare’s manual tells providers to follow 55 Pa. Code § 1101.64 and to "Request prior authorization the same way that they always have from both the BH-MCOs and the private insurance companies", noting that PerformCare authorization is not a guarantee of payment without a primary denial or non-coverage document. Claims for members with commercial or Medicare primary need… full guide →
Source ↗PerformCare pays IBHS at rates set by county-contract rate notices and provider agreements; current ABA rates were not published in the documents reviewed. Ask your PerformCare Account Executive for the current IBHS rate schedule for your county contract.
Source ↗1. Written order From a licensed practitioner with an active PROMISe ID, face-to-face, within 12 months of initiation, naming a DSM/ICD behavioral health diagnosis, clinical support, maximum hours of each service per month, settings and measurable discharge markers. In-network order writers submit the order to Carelon and the county through ProviderConnect within 7 business… full guide →
Source ↗Carelon’s HealthChoices Covered Services Grid (PV 07/22/2026) is the claims source of truth: IBHS ABA codes are billed by PROMISe provider type 11, specialty 592 with "Auth Req? Y" for 97151 (BC-ABA; U7 for behavior analytic), 97152/97153 (BHT-ABA; U8 for assistant BC-ABA), 97155 and 97156 — while the assessment service class billed as 97151 AO or AP carries "Auth Req? N".… full guide →
Source ↗Carelon’s Act 62 FAQ: a child is Act 62 eligible with an ASD diagnosis and primary insurance; the Act 62 cover sheet goes with every new authorization request (only the top portion if there is no primary). When the primary covers autism services, Carelon issues an acknowledgement letter that services are covered under Act 62 and "will be reviewed for Medical Necessity once the… full guide →
Source ↗Carelon pays under provider agreements; the covered-services grid lists codes, modifiers and places of service but not rates, and no public Carelon PA IBHS fee schedule was found. Confirm rates with your Carelon Provider Field Coordinator.
Source ↗Highmark’s Pennsylvania commercial policy V-37-044 (effective August 4, 2025) covers ABA when every criterion is met. The child has a DSM-5 ASD diagnosis. A qualified behavior analyst used a standardized assessment to find impairment in social communication and interaction, restricted or repetitive behavior, or activities of daily living. A state-licensed physician (MD/DO) or… full guide →
Source ↗Highmark announced in November 2025 that it would add 19 behavioral health codes to its prior authorization list on March 1, 2026. These include all ten ABA codes: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T. The list effective 09/01/2026 carries them, plus H0032 and H2019, under “Applied Behavioral Analysis”, with “Highmark Behavioral Health” as… full guide →
Source ↗V-37 repeats Act 62 almost word for word. The mandate applies to group contracts issued or renewed on or after July 1, 2009 for fully insured employers with 51 or more employees, and to CHIP. The treatment plan must come from a physician or psychologist after a comprehensive evaluation. Highmark may review it once every six months under its utilization review rules, or on… full guide →
Source ↗Highmark’s eligible-provider policy (Z-27-037, effective October 13, 2025) lists “Behavior health rehabilitation agency providers (solely for the diagnosis or treatment of autism spectrum disorders)” and “Behavior specialist” among eligible professional providers. Highmark also pays for services by state-licensed or state-certified practitioners employed and supervised by an… full guide →
Source ↗Commercial ABA rates are negotiated in the provider agreement, and Highmark’s fee schedules are behind the Availity login. The exception is CPT 97153. On August 17, 2026 Highmark announced new 97153 reimbursement for applicable commercial products, effective October 16, 2026. For PA PPO it is $16.59 in the office and $15.73 outside the office (97153 is a 15-minute code).… full guide →
Source ↗A Highmark Wholecare card is a Medicaid (HealthChoices) physical-health plan, not Highmark commercial coverage. Wholecare’s member handbook says behavioral health services “are provided through behavioral health managed care organizations (BH-MCOs)”, assigned by county. In Pennsylvania Medicaid, ABA is part of Intensive Behavioral Health Services (IBHS), so a Wholecare child’s… full guide →
Source ↗Pennsylvania has no behavior-analyst license, and the BACB licensure table has no Pennsylvania entry. Under Act 62 § 635.2(g), the State Board of Medicine licenses Behavior Specialists (49 Pa. Code §§ 18.521–18.527), and Highmark’s Z-27 lists “Behavior specialist” as an eligible provider. Highmark’s V-37 separately accepts BCBAs, BCaBAs and RBTs under supervision. Confirm… full guide →
Source ↗The Provider Manual says “Applied Behavior Analysis treatment services require a preauthorization prior to beginning treatment.” Requests go through the Preauthorization application in the Provider Portal with the plan of care, clinical notes and other clinical documents. The same package supports concurrent (continued-stay) review. Capital also offers a standard ABA Progress… full guide →
Source ↗Capital’s autism medical policy, MP 2.304 “Medical Treatments of Autism Spectrum Disorder” (effective 8/1/2026), no longer covers ABA. Its history notes that in 2023 “ABA and Behavior therapy removed from policy”, and in 2024 it removed “statements related to behavioral health services”. What remains covers diagnostic evaluation and investigational treatments. Its product… full guide →
Source ↗The manual’s utilization-management table names ABA in its outpatient rows. Standard outpatient requests: for Commercial, FEP, Exchange and Managed Care, a missing-information notice within 48 hours and a decision within 15 calendar days. For CHIP, a decision within two business days. Expedited outpatient requests: Commercial, Exchange and Managed Care decide “ASAP but within… full guide →
Source ↗Act 62 requires fully insured group policies for employers with 51 or more employees, and CHIP, to cover diagnostic assessment and treatment of ASD, including ABA, for members under 21. The treatment plan must come from a licensed physician or psychologist. The insurer may review it once every six months. A diagnostic assessment is valid for 12 months. Capital’s manual states… full guide →
Source ↗Capital manages behavioral health preauthorization itself. The manual names no outside behavioral health vendor for ABA. However, “some employer groups have made alternative arrangements for behavioral health services”, and in that case the member’s ID card shows where behavioral health benefits sit. Read the card before you request authorization. Telehealth is governed by… full guide →
Source ↗Pennsylvania has no behavior-analyst license, and the BACB licensure table has no Pennsylvania entry. Under Act 62 § 635.2(g), the State Board of Medicine licenses Behavior Specialists (49 Pa. Code §§ 18.521–18.527). Act 62 defines an “autism service provider” as one licensed or certified in Pennsylvania. Capital’s manual requires every rendering practitioner to be… full guide →
Source ↗Effective April 1, 2026, "all Applied Behavior Analysis (ABA) services for Independence Blue Cross (IBX) and Independence Administrators members will be managed by the IBX Care Management team instead of Magellan Healthcare". Authorizations Magellan issued before that date stand until they run out; any subsequent review goes to IBX on the new ABA Prior Authorization Form.… full guide →
Source ↗IBX’s commercial ABA policy is Medical Policy Bulletin 14.00.03b, "Applied Behavior Analysis (ABA) for the Treatment of Autism Spectrum Disorder (ASD)" (version effective 12/29/2025). Initial ABA is covered when all of these are met: an established DSM-5-TR ASD diagnosis made with validated autism tools (ADOS, ADI-R, PEDS or Brigance are the examples); target behaviors or… full guide →
Source ↗IBX’s commercial precertification list (effective July 1, 2026) names all ten ABA codes — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T — with IBX itself performing the review. The list applies to "all fully insured groups, most self-funded groups and all members with individual coverage", with the standing caveat that self-funded employers "may… full guide →
Source ↗Pennsylvania’s autism mandate, Act 62 of 2008, requires insured policies issued to groups of 51 or more employees (and CHIP) to cover the diagnostic assessment and treatment of ASD, including ABA, for covered individuals under 21. The statutory annual maximum is CPI-adjusted — $51,908 for policies issued or renewed in 2026 and $53,310 in 2027 — but the Insurance Department… full guide →
Source ↗Pennsylvania has no behavior-analyst licensure law; the State Board of Medicine licenses Behavior Specialists under Act 62. IBX’s own rule is credentialing: master’s and doctoral BCBAs must pass IBX credentialing before contracting, "Only credentialed Providers may bill ABA services as in-network Providers", and a group is in network only if the group is contracted and every… full guide →
Source ↗UPMC’s commercial provider manual says it plainly: "Behavioral health and substance use disorder benefits are managed through UPMC Health Plan." Urgent after-hours authorization requests go to Community Care Behavioral Health, and providers reach UPMC Health Plan Behavioral Health Services (BHS) 24/7 at 1-866-441-4185 (members: 1-888-251-0083). Members may self-refer to a… full guide →
Source ↗We read the full index of UPMC Health Plan’s Policies & Procedures Manual — 524 clinical, medical, prior-authorization and pharmacy policies — and it contains no ABA or autism medical policy. The behavioral health chapter of the provider manual (Chapter L, updated August 2025) has authorization tables for inpatient, residential, partial hospitalization, intensive outpatient… full guide →
Source ↗On UPMC commercial policies issued to groups of 51 or more employees (and on UPMC for Kids, which is CHIP), Act 62 requires coverage of the diagnostic assessment and treatment of ASD — including ABA — for members under 21. It sets a CPI-adjusted statutory maximum of $51,908 for 2026 policies ($53,310 in 2027), but the Insurance Department expects that cap to have no effect… full guide →
Source ↗UPMC’s telemedicine policy MP.148 (effective October 2025) covers all commercial lines and lists 0362T, 0373T and 97151 through 97158 among its "Commercial, CHIP and Medicare Codes". For commercial members, audio-video is mandatory: "Audio-only (telephone) sessions will be denied as not medically necessary." Claims must carry POS 02 or 10, the platform must be HIPAA-compliant… full guide →
Source ↗Geisinger’s ABA coverage lives in medical policy MP232, "Autism Spectrum Disorder – Evaluation and Medical Management", which applies to Commercial, ACA, CHIP, Medicaid and Medicare lines. The policy says it "is consistent with Pennsylvania state mandated coverage for autism spectrum disorder" and that some provisions "may apply only to those contracts subject to PA Act 62."… full guide →
Source ↗The guideline MP232 points to is OMHSAS-17-01, a Medical Assistance bulletin written for the old BSC-ASD/TSS model. For a prior-authorization request it asks for: the most recent face-to-face evaluation or re-evaluation by a board-certified or board-eligible child and adolescent psychiatrist, developmental pediatrician, pediatric neurologist or licensed child psychologist (or,… full guide →
Source ↗GHP’s prior authorization list (updated August 24, 2026) groups ABA with other non-routine behavioral health services and lists 97151–97158, 0362T and 0373T. Its note reads: "Effective 7/15/2023, ABA service will require a Prior Authorization when billed for any diagnosis except Autism." The provider forms page says the same for network providers: "In-network applied… full guide →
Source ↗On Geisinger policies issued to groups of 51 or more employees (and on GHP Kids, which is CHIP), Act 62 guarantees coverage of the diagnostic assessment and treatment of ASD, including ABA, for members under 21. The CPI-adjusted statutory maximum is $51,908 for 2026 ($53,310 in 2027), which the Insurance Department expects to have no effect under parity. Act 62 lets the… full guide →
Source ↗Aetna’s ABA rules are national. Its ABA medical necessity guide sets the criteria: a DSM-5 ASD diagnosis, functional impairment on a standardized scale in the past 12 months, a measurable treatment plan, and progress reviewed every six months. CPB 0648 covers the autism evaluation and CPB 0554 calls ABA unproven for non-ASD indications. Aetna’s participating-provider… full guide →
Source ↗Pennsylvania’s autism mandate is Act 62 of 2008 (Insurance Company Law § 635.2, 40 P.S. § 764h). For covered individuals “under twenty-one (21) years of age” it requires coverage of the diagnostic assessment of autism spectrum disorder and of its treatment, and treatment includes rehabilitative care such as applied behavior analysis identified in a treatment plan. Coverage is… full guide →
Source ↗Who may diagnose The “diagnostic assessment” is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner. Diagnosis valid 12 months “The results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of twelve (12) months”, unless a licensed physician or licensed psychologist… full guide →
Source ↗We checked. Aetna’s ABA medical necessity guide carries exactly one state exhibit, Exhibit A for Maryland plans under COMAR 31.10.39, and nothing for Pennsylvania. Its cover note says only that “Other state laws and regulations may apply in other states.” The behavioral health precertification list has no Pennsylvania carve-out either; its only state note exempts fully insured… full guide →
Source ↗Aetna’s guide says services “must be provided directly or billed by” licensed behavior analysts (in states with licensure laws), board-certified behavior analysts, or licensed psychologists whose scope covers behavior analysis, “unless state mandates, plan documents or contracts require otherwise”. Anyone else needs supervision in line with practice standards. The provider… full guide →
Source ↗Many Pennsylvania children with commercial coverage also carry Medical Assistance as a second payer. PH-95 (“Medicaid for Children with Special Needs”) covers children under 18 with SSA-standard disabilities, and “Parental income must be verified but will be excluded in this category”. Medical Assistance pays last. Other private or governmental health insurance must be used… full guide →
Source ↗Pennsylvania has no behavior-analyst licensure law: the BACB’s U.S. licensure table carries no Pennsylvania entry. Act 62 had the State Board of Medicine license “behavior specialists” instead. The license requires a master’s degree in a listed field (behavioral analysis included), one year of functional-behavior-assessment experience with individuals under 21, 1,000 hours of… full guide →
Source ↗Cigna manages ABA through Evernorth Behavioral Health under national coverage policy EN0499 (Intensive Behavioral Interventions, effective 5/15/2026). The front door is easy: under the autism resource guide, assessment codes 97151, 97152 and 0362T need no prior authorization when the provider is independently licensed or a BCBA and the policy covers ABA. The hard part is the… full guide →
Source ↗Pennsylvania’s autism mandate is Act 62 of 2008 (Insurance Company Law § 635.2, 40 P.S. § 764h). For covered individuals “under twenty-one (21) years of age” it requires coverage of the diagnostic assessment of autism spectrum disorder and of its treatment, and treatment includes rehabilitative care such as applied behavior analysis identified in a treatment plan. Coverage is… full guide →
Source ↗Who may diagnose The “diagnostic assessment” is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner. Diagnosis valid 12 months “The results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of twelve (12) months”, unless a licensed physician or licensed psychologist… full guide →
Source ↗We ran a full-text check of the current EN0499. Its only state references are New York, given as an example of a state mandate, and Virginia, whose fully insured business is not subject to the policy. Pennsylvania is not mentioned, so Pennsylvania Cigna members follow standard EN0499 criteria unless their plan documents differ. The no-assessment-PA path holds. Evernorth bases… full guide →
Source ↗Many Pennsylvania children with commercial coverage also carry Medical Assistance as a second payer. PH-95 (“Medicaid for Children with Special Needs”) covers children under 18 with SSA-standard disabilities, and “Parental income must be verified but will be excluded in this category”. Medical Assistance pays last. Other private or governmental health insurance must be used… full guide →
Source ↗Pennsylvania has no behavior-analyst licensure law: the BACB’s U.S. licensure table carries no Pennsylvania entry. Act 62 had the State Board of Medicine license “behavior specialists” instead. The license requires a master’s degree in a listed field (behavioral analysis included), one year of functional-behavior-assessment experience with individuals under 21, 1,000 hours of… full guide →
Source ↗UnitedHealthcare manages commercial ABA through Optum under the ABA Supplemental Clinical Criteria (BH803ABASCC). ABA needs prior authorization, and on the Provider Express portal the assessment and the treatment are requested as separate authorizations. The criteria require a DSM-5-TR diagnosis confirmed with a validated tool, supervision at 1–2 hours per 10 hours of direct… full guide →
Source ↗Pennsylvania’s autism mandate is Act 62 of 2008 (Insurance Company Law § 635.2, 40 P.S. § 764h). For covered individuals “under twenty-one (21) years of age” it requires coverage of the diagnostic assessment of autism spectrum disorder and of its treatment, and treatment includes rehabilitative care such as applied behavior analysis identified in a treatment plan. Coverage is… full guide →
Source ↗Who may diagnose The “diagnostic assessment” is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner. Diagnosis valid 12 months “The results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of twelve (12) months”, unless a licensed physician or licensed psychologist… full guide →
Source ↗Pennsylvania Commercial is on the list of states whose ABA State Mandates entry Optum applies alongside the national criteria, and “To the extent this criteria conflicts with applicable state-mandated criteria, the state-mandated criteria controls.” The Pennsylvania entry (State Mandates document effective July 2026) says two things. First, coverage is required for the… full guide →
Source ↗UnitedHealthcare Community Plan Pennsylvania is one of the managed care plans covering Pennsylvania CHIP enrollees, and Optum builds and manages its ABA network. Act 62 applies to CHIP contracts too. Optum’s Pennsylvania CHIP quick reference guide (11/2022) says “All autism services require prior authorization”, bills on a CMS-1500 to payer ID 87726, sets a 180-day filing… full guide →
Source ↗Many Pennsylvania children with commercial coverage also carry Medical Assistance as a second payer. PH-95 (“Medicaid for Children with Special Needs”) covers children under 18 with SSA-standard disabilities, and “Parental income must be verified but will be excluded in this category”. Medical Assistance pays last. Other private or governmental health insurance must be used… full guide →
Source ↗Pennsylvania has no behavior-analyst licensure law: the BACB’s U.S. licensure table carries no Pennsylvania entry. Act 62 had the State Board of Medicine license “behavior specialists” instead. The license requires a master’s degree in a listed field (behavioral analysis included), one year of functional-behavior-assessment experience with individuals under 21, 1,000 hours of… full guide →
Source ↗Next up: New Jersey · Colorado · Arizona · Utah · Texas · Florida · TRICARE (Autism Care Demonstration). New guides are added on a rolling basis, and every published guide’s sources are automatically re-checked on a schedule. Need a payer covered sooner? Tell us which one.
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